Pamela Youde Nethersole Eastern Hospital announces root cause analysis report of previous 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) today (December 17) announced the root cause analysis report of a previous event involving the insertion of a nasogastric tube.

     A 76-year-old male patient was clinically admitted to PYNEH on October 9 in preparation for a colonoscopy. Owing to his clinical needs, a nasogastric (NG) tube was inserted on the day of admission for drug administration. The NG tube was subsequently found to have been misplaced and the medication had entered the patient's lungs. After the NG tube was removed and appropriate treatment was provided, the patient's condition gradually improved and he was discharged from the hospital on October 23.

     A Root Cause Analysis Panel (the Panel) was subsequently set up to identify the causes. The Panel completed the investigation and has submitted the report to the Hospital Authority Head Office (HAHO). The Panel was of the view that the intern who reviewed the X-ray images did not have adequate clinical experience in interpreting the findings correctly and did not seek assistance from supervisors, thus failing to make a timely judgment that the NG tube was improperly positioned.

     The Panel made the following recommendations:
 

1. enhance simulation training or scenario-based training on topics associated with a high-risk procedure for interns to enhance their knowledge and clinical risk awareness;
2. enhance the competency assessment for interns regarding the confirmation of NG tube positions on X-rays; and
3. enhance the mentorship programme for interns to provide clinical and decision support, and encourage a speak-up culture among junior staff.

     The HAHO has made arrangements for all interns to complete the training and competency assessment on the confirmation of NG tube positions on X-rays by the end of October this year. The HA will continue to arrange different on-the-job training programmes to enhance the clinical standards of interns.

     PYNEH accepted the investigation findings and recommendations. The hospital will implement the relevant recommendations and continue to enhance the training and supervision for interns in collaboration with the HAHO. The hospital again apologised to the patient and his family for the incident.

     The hospital also expressed gratitude for the work of the Panel. 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