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Queen Elizabeth Hospital announces sentinel event

HK

Queen Elizabeth Hospital announces sentinel event
HK

HK

Queen Elizabeth Hospital announces sentinel event

2024-06-19 22:48 Last Updated At:22:58

Patient in critical condition after nasogastric tube misplacement at queen elizabeth hospital; investigation underway to determine root cause

The following is issued on behalf of the Hospital Authority:

The spokesperson for Queen Elizabeth Hospital (QEH) announces a sentinel event today (June 19):

A 61-year-old male patient, feeding with a nasogastric tube, was arranged to feed with formula milk after replacing a new tube by healthcare staff in an Orthopedic ward of QEH. While the patient’s condition deteriorated afterwards, it was revealed that the nasogastric tube was not placed in an appropriate position.

The hospital is highly concerned about the incident. After preliminary review, it was revealed that a new nasogastric tube was inserted by a nurse on June 16 noon according to the established arrangement. Another nurse examined the patient in the evening and considered reinsertion of the nasogastric tube was needed. The nurse followed the established protocol to collect aspirated fluid samples for pH test and to verify the position by auscultation. Feeding of formula milk was then resumed, followed by a chest X-ray examination for the patient.

The patient's condition suddenly deteriorated in the early morning of June 18. Doctors immediately performed resuscitation and arranged bronchoscopy examination for the patient, where a nasogastric tube was found placed in his bronchus. The tube was immediately removed by doctor and the patient was transferred to the High Dependency Unit for close monitoring. The patient is now hospitalised in the Intensive Care Unit with critical condition. The clinical team will continue to closely monitor the patient's clinical condition and provide appropriate treatment.

The hospital is saddened by the incident. QEH has met with the patient’s family to explain the incident, extend sincere apologies and express deep empathy. QEH will continue to closely communicate with the patient’s family and provide necessary assistance.

The QEH is very concerned about the incident, and has reported to the Hospital Authority Head Office through the Advance Incident Reporting System. A Root Cause Analysis Panel has been set up to investigate the root cause of the incident. The panel will submit report and recommend improvement measures within eight weeks. The panel members are as follows:

Chairperson:

Dr Tang Kam-shing

Hospital Chief Executive, Kwong Wah Hospital

Members:

Dr Fong Wing-chi

Chief of Service, Department of Medicine, Queen Elizabeth Hospital

Ms Li Wah-chun

Cluster General Manager (Nursing), Kowloon Central Cluster

Dr Leung Chi-shing

Consultant, Department of Medicine and Geriatrics, Caritas Medical Centre

Mr Yip Chun-ki

Department Operations Manager, Department of Medicine, Queen Mary Hospital

Ms Chiu So-yan

Manager (Patient Safety and Risk Management), Hospital Authority

Source: AI-generated images

Source: AI-generated images

HKSAR Government highly concerned about Microsoft system outage

The Hong Kong Special Administrative Region Government is highly concerned about the massive technical outage of Microsoft system today (July 19) and has assigned the Deputy Chief Secretary for Administration (DCS) to monitor the situation. The DCS has asked government departments to closely keep in view developments under their purview and be prepared to make prompt response as well as immediate reports where necessary. The DCS will also give instructions as necessary.

The operation of government systems has remained normal and no incident report is received from departments in relation to their systems (including critical infrastructures under their purview). As regards individual airlines whose systems are affected by the Microsoft system outage, the Hong Kong International Airport has immediately activated the emergency response system to minimise the impact of the incident on travellers.

The Office of the Government Chief Information Officer has communicated with Microsoft and urged the company to release solution to the public and provide support to affected users as soon as possible.

Source: AI-generated images

Source: AI-generated images

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