Caritas Medical Centre announces root cause analysis report of previous sentinel event
The following is issued on behalf of the Hospital Authority:
The spokesperson for Caritas Medical Centre (CMC) today (May 6) announces the root cause analysis report of a previous sentinel event:
A 75-year-old male non-communicative patient with a history of hypertension and Alzheimer's disease was admitted to CMC for abdominal pain and constipation on February 28. According to hospital records, the patient started a puree diet instead of a minced diet in February.
The patient was restricted from eating and drinking until March 2, when a fluid diet was resumed as his condition improved. On March 3, a doctor ordered DAT (abbreviation of the term "diet as tolerated"), intending to resume the patient's usual diet, while the term concerned was interpreted as a regular diet by a nurse. The patient choked while being fed a regular diet and passed away during the afternoon on the same day despite resuscitation efforts.
CMC announced the incident afterward and a Root Cause Analysis Panel was formed to analyse the incident. After reviewing the case, the Panel concluded that the root cause of the incident was the varied interpretations of the term concerned, which led to communication gaps and misaligned practices among the clinical team.
The Panel considered that multiple factors were involved in this sentinel event. There was a lack of communication between medical and nursing staff regarding dietary orders. The inclusion of a DAT as a standard diet type in some electronic systems might have created the perception that the instruction referred to a specific diet type. Additionally, some nursing teaching materials equate the term with a regular diet, which could also have contributed to varied understanding in daily clinical practice.
The Panel also found that DAT was not a standard option in the electronic bed panel system, but the term concerned was entered as free text, leading to varying interpretations of the patient's dietary requirements. Moreover, there was no standardised process for patient assessment, diet selection, and documentation of diet tolerance.
The Panel made the following recommendations:
- The interpretation of the term DAT should be aligned and communicated to staff;
- The use of DAT as a diet type option in all forms and electronic systems should be removed to eliminate ambiguity;
- The dietary management workflow from patient assessment to communication to meal provision should be enhanced; and
- The terminology for diet options in the Dietetics and Catering Order System should be standardised with the electronic bed panel system. The interface between these systems should be improved to synchronise data and minimise the risk of misinterpreting dietary orders.
The Hospital Authority (HA) has aligned the definition of the term DAT. It is now explicitly defined as a flexible dietary approach tailored to the patient's individual tolerance, preferences, and medical condition, subject to professional assessment. It does not imply any specific food texture.
CMC will implement the relevant recommendations to enhance medical and nursing staff training to ensure proper understanding and implementation of the aligned definition of the term concerned in daily practice. The hospital has met with the patient's family to explain the report's findings, and expressed deep condolences to the family members. CMC will maintain communication with the family and provide necessary assistance.
CMC has submitted the report to the HA Head Office. The hospital also expressed gratitude to the panel. Membership of the panel is as follows:
Chairperson:
Dr Lau Ka Hin
Clinical Stream Coordinator (Medical), Hong Kong East Cluster
Members:
Professor Chair Sek Ying
Vice-Director of Research, The Nethersole School of Nursing, Faculty of Medicine, the Chinese University of Hong Kong
Mr Chan Man Nok
Chief Nursing Officer, Nursing Services Department, Hospital Authority
Ms Sandy Chang
Cluster Manager (Dietetics), Kowloon Central Cluster
(Joined on March 6)
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
Mr Lam Yan Ki
Department Manager (Speech Therapy), Kowloon East Cluster
Dr Lau Chi Hung
Chief of Service (Surgery), Queen Elizabeth Hospital
Dr Ben Wong
Clinical Services Coordinator (Surgery), Caritas Medical Centre
Source: AI-generated images
