Tuen Mun Hospital reveals a guard occasion
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The following is provided on behalf of the Hospital Authority:
The representative for Tuen Mun Hospital (TMH) made the following statement today (May 14) relating to a guard occasion:
A 75-year-old male client with persistent obstructive lung illness (COPD) and hyperlipidemia was confessed to a medical and geriatric ward in TMH on May 6 due to a worsening of COPD. He was identified with severe coronary syndrome made complex by myocardial infarction and was set up to go through for Percutaneous Coronary Intervention (PCI) on May 11.
Throughout the treatment, coronary angiogram exposed an air bubble in the client’s artery. The medical group right away examined the high blood pressure tracking gadget and other linked devices. No irregularity was identified. The client’s condition stayed steady and the medical group continued with the treatment after scientific evaluation, with close tracking of the devices and the client’s condition. After about 30 minutes, numerous air bubbles were found once again in client’s artery. The client consequently established bradycardia and hypotension. Resuscitation was started instantly. The client continued to degrade and surrendered on the very same day.
Upon preliminary assessment of the treatment and the secondhand devices, medical group determined an irregularity in the luer lock adapter of an extension tube. In basic, catheters, adapters and associated gadgets utilized in PCI treatments must be airtight to avoid micro air emboli going into the blood stream.
The healthcare facility was distressed by the diing of the client. TMH group has actually talked to with the client’s household to discuss the occurrence and reveal inmost acknowledgement. The medical facility will keep close interaction with the household and deal possible help.
The event has actually been reported to the Hospital Authority Head Office (HAHO) through the Advance Incident Reporting System. A Root Cause Analysis Panel is established to check out the event. The scope of the examination will consist of the associated devices, treatments, operations and other possible contributing elements. A report with suggested suggestions will be sent to the HAHO within 8 weeks. The occurrence has actually been reported to the worried maker of the devices and the Department of Health for follow-up. The occurrence has actually likewise been reported to the Coroner for follow-up.
Subscription of the panel is as follows:
Chairperson:
Dr Carmen Chan
Deputy Chief of Service (Medicine), Queen Mary Hospital
Members:
Ms Chi Chui-yee
Department Operations Manager (Medicine and Geriatrics), Tuen Mun Hospital
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
Dr Tam Li-wah
Chief of Service (Medicine and Geriatrics), Kwong Wah Hospital/ Tung Wah Group Of Hospitals Wong Tai Sin Hospital
Dr Wong Chi-wing
Specialist (Medicine and Geriatrics), Pok Oi Hospital/ Tin Shui Wai Hospital
Mr Bill Wang
Vice-Chairman, Hong Kong Kidney Foundation
Ms Gigi Yiu
Nurse Consultant (Cardiac Care), New Territories East Cluster