Kwong Wah Hospital announces sentinel event

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Kwong Wah Hospital announces today (February 8) a sentinel event:

     A 51-year-old male patient was admitted to the isolation ward of Kwong Wah Hospital due to shortness of breath on December 16, 2023. He was later transferred to the Intensive Care Unit due to sepsis shock and respiratory failure and required the support of a ventilator. His condition was critical. He was diagnosed with pulmonary tuberculosis after an investigation. After receiving treatment, he was transferred to the isolation ward at around 2.30pm on February 5 to continue his treatment. The patient was conscious but still required the support of a ventilator. 

     In order to ensure the patient's safety, healthcare staff applied upper limb restrainer to secure the patient on the bed to prevent his body movement from causing disconnection with the ventilator tubes. The healthcare staff then checked the ventilator and other medical equipment and confirmed that they were in normal function, and then left the room at 3.20pm. The healthcare staff later entered the room again at 3.45pm to observe the patient's condition and recorded the ventilator data. There was no abnormalities observed and the staff left at 3.55pm. At 4.40 pm, when the healthcare staff entered the room for medical procedures, the ventilator tubes connected to the patient were found detached. The patient was unresponsive with no pulse. The healthcare staff immediately reconnected the ventilator tubes and performed resuscitation. The patient's pulse recovered and was transferred to the Intensive Care Unit. He is currently in critical condition.

     The hospital is very concerned about the incident and has conducted a review, including the records of the ventilator and the operation of other medical equipment. After a preliminary investigation, it is believed that the ventilator tubes were detached after the healthcare staff left the room due to the movement of the patient. However, the healthcare staff outside the room were unable to note the alert sound from the ventilator immediately as the negative pressure isolation room is equipped with double doors. In addition, there was suspected connection abnormality of the vital index monitoring equipment connected to the patient. Therefore, the healthcare staff at the nurse station was not being alerted when there was abnormality in the patient's condition. 
      
     The hospital has informed the family members explaining the incident. The incident has been reported to the Hospital Authority Head Office via the Advance Incident Reporting System. A Root Cause Analysis Panel has been set up to look into the incident and aimed to set out enhanced measures to ascertain the safety of patients using ventilators in the negative pressure isolation room. The panel members are as follows:

Chairperson
Dr Yan Wing-wa           
Consultant, Hyper-baric Oxygen Therapy Centre, Pamela Youde Nethersole Eastern Hospital

Members 
Dr Yeung Yiu-cheong   
Deputy Chief of Service, Department of Medicine and Geriatrics, Princess Margaret Hospital
Dr Helen Yip                 
Consultant, Department of Medicine and Geriatrics, Kwong Wah Hospital
Mr Li Chi-man               
Ward manager, Department of Medicine and Geriatrics, Kwong Wah Hospital 
Ms Terry Ko                   
Department Operation Manager, Department of Medicine, North District Hospital 
Dr Nicole Chau               
Senior Manager (Patient Safety & Risk Management), Hospital Authority

     The panel will complete the investigation and recommend improvement measures within eight weeks. The report will be submitted to the Hospital Authority Head Office.

     The Hospital Authority has also informed the manufacturer of the equipment about the incident and requested the manufacturer to review the case to strengthen patient safety.