Pamela Youde Nethersole Eastern Hospital announces event involving insertion of nasogastric tube

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Pamela Youde Nethersole Eastern Hospital (PYNEH) made the following announcement today (October 10) regarding an event involving insertion of nasogastric tube:

     A 76-year-old male patient was clinically admitted to PYNEH yesterday (October 9) for a scheduled colonoscopy. Owing to his clinical needs, a nasogastric tube was inserted on the day of admission for drug administration. The nasogastric tube was subsequently found to have been misplaced in the bronchus and the medication has entered the patient's lungs. In view of the episode of transient deterioration of the condition, the patient was subsequently transferred to Intensive Care Unit for further support. The patient is in critical condition but had gradually improved after treatment.

     After initial investigation, it was found that the procedure for verifying nasogastric tube position was in compliance with the prevailing guideline. A chest X-ray was arranged to confirm the tube position. It was suspected that an intern doctor had misinterpreted the chest X-ray findings, and could not identify that the nasogastric tube was misplaced in the bronchus. Following drug administration, the patient developed abdominal pain and shortness of breath. Immediate assessment and treatment were provided to the patient. The nasogastric tube was found to be misplaced in the bronchus upon re-examination of the chest X-ray.

     PYNEH is very concerned about the incident and has contacted the patient's family to provide explanation and extend sincere apologies. PYNEH will continue to closely communicate with the patient's family and provide necessary assistance to them. Meanwhile, the hospital has reported the case to the Hospital Authority Head Office (HAHO) through the Advance Incident Reporting System, and will continue to enhance training and supervision for interns. A Root Cause Analysis Panel will be set up for investigation. The report will be submitted to HAHO in eight weeks. The Panel members are as follows:

Chairperson:
Dr Michael Wong
Director (Quality and Safety), Hospital Authority

Members:
Dr Ng Man-fai
Consultant, Department of Medicine and Geriatrics, Tuen Mun Hospital

Ms Louisa Leung
Senior Manager (Nursing), Hospital Authority

Dr Nicole Chau
Senior Manager (Patient Safety and Risk Management), Hospital Authority

Dr Sara Ho
Service Director (Quality and Safety), Hong Kong East Cluster

Mr Mok Long-chau
Cluster General Manager (Nursing), Hong Kong East Cluster