United Christian Hospital announces root cause analysis report of previous incident involving insertion of nasogastric tube
The following is issued on behalf of the Hospital Authority:
The spokesperson for United Christian Hospital (UCH) today (25 July) announced the root cause analysis report of an incident involving the insertion of a nasogastric tube.
A patient, under the Ear, Nose and Throat Department of UCH, underwent surgery on May 26, during which a nasogastric tube was inserted to facilitate postoperative administration of medication and feeding of formula milk. The patient was admitted to the Intensive Care Unit (ICU) for close monitoring after the surgery and was arranged for an X-ray examination to verify the position of the nasogastric tube. However, the X-ray image was not reviewed by a doctor afterwards. The nurse then performed a pH test on the gastric aspirate from the patient's nasogastric tube and began nasogastric tube feeding for the patient with drugs and formula milk according to the pH test result, established protocols, and the doctor's order. Healthcare staff later reviewed the patient and suspected that there was a malposition of the nasogastric tube. Feeding was terminated, and the nasogastric tube was removed immediately. The patient's clinical condition continued to improve, and the patient was discharged in late June.
UCH announced the incident on May 30 and appointed a Root Cause Analysis Panel for investigation. After reviewing the case, the Panel concluded that the main cause leading to the incident was the lack of a closed-loop mechanism in the ICU to ascertain that X-ray images were reviewed to verify the position of the nasogastric tube before initiating nasogastric tube feeding for patients.
The Panel believed that the incident also involved other contributing factors, including the X-ray images' review status not being incorporated into the clinical handover process, which led to clinical teams involved not noticing that the X-ray images had not been reviewed; and the lack of a mechanism to alert doctors to follow up on the unreviewed X-ray images. Moreover, the pH test result from the patient's gastric aspirate sample was consistent with the pH reading of gastric fluid, which led the clinical team to mistakenly believe that the nasogastric tube was in the right position.
The Panel made the following recommendations:
1. Establish a closed-loop mechanism in the ICU to alert clinical teams to review X-ray images to ascertain the position of the tube before initiating nasogastric tube feeding for patients;
2. Incorporate X-ray image review into the clinical handover process and postoperative checklist to ensure that X-ray images are reviewed to ascertain the position of the nasogastric tube before initiating nasogastric tube feeding for ICU patients;
3. Utilise electronic Clinical Information System in the ICU to standardise the clinical documentation of nasogastric tube position;
4. Review and update relevant nursing clinical guidelines; and
5. Arrange ICU healthcare staff to attend Crew Resources Management simulation training for improving team communication, teamwork, situational awareness and decision making.
UCH will take follow-up actions to implement the recommendations. The hospital has explained the report's findings to the patient and family concerned and expressed its apology again to them. Patient Relations Team shall continue to provide necessary assistance to the family.
The report has been submitted to the Hospital Authority (HA) Head Office. The hospital expressed gratitude for the work of the Root Cause Analysis Panel. The membership of the panel is as follows:
Chairperson:
Dr Victor Ip
Service Director (Quality & Safety), Kowloon East Cluster, HA
Members:
Dr Chan Ka-hing
Consultant, Department of Intensive Care, Tseung Kwan O Hospital
Dr James Wesley Cheng
Deputy Service Director (Quality & Safety), Kowloon East Cluster, HA
Dr Raymond Cheung
Chief Manager, Quality & Safety Division (Patient Safety & Risk Management), HA
Dr Joseph Chung
Chief of Service, Department of Ear, Nose & Throat, Queen Mary Hospital
(Replace Dr Eddy Wong)
Ms Ho Ka-man
Department Operations Manager, Department of Intensive Care, Prince of Wales Hospital
Mr Leung Lok-man
Cluster General Manager (Nursing), Kowloon East Cluster, HA
Dr George Ng
Chief of Service, Intensive Care Unit, Queen Elizabeth Hospital
Source: AI-found images
