A 75-year-old Patient Dies at the Procedure of Percutaneous Coronary Intervention at Tuen Mun Hospital, Investigation Launched

Tuen Mun Hospital announces a sentinel event

The following is issued on behalf of the Hospital Authority:

The spokesperson for Tuen Mun Hospital (TMH) made the following announcement today (May 14) regarding a sentinel event:

A 75-year-old male patient with chronic obstructive pulmonary disease (COPD) and hyperlipidemia was admitted to a medical and geriatric ward in TMH on May 6 due to an exacerbation of COPD. He was diagnosed with acute coronary syndrome complicated by myocardial infarction and was arranged to undergo for Percutaneous Coronary Intervention (PCI) on May 11.

During the procedure, coronary angiogram revealed an air bubble in the patient's artery. The clinical team immediately checked the blood pressure monitoring device and other connected equipment. No abnormality was detected. The patient's condition remained stable and the clinical team proceeded with the procedure after clinical assessment, with close monitoring of the equipment and the patient's condition. After about 30 minutes, multiple air bubbles were detected again in patient's artery. The patient subsequently developed bradycardia and hypotension. Resuscitation was initiated immediately. The patient continued to deteriorate and succumbed on the same day.

Upon initial inspection of the procedure and the used equipment, clinical team identified an abnormality in the luer lock connector of an extension tube. In general, catheters, connectors and related devices used in PCI procedures should be airtight to prevent micro air emboli entering the bloodstream.

The hospital was saddened by the passing away of the patient. TMH team has interviewed with the patient's family to explain the incident and express deepest condolence. The hospital will maintain close communication with the family and offer possible assistance.

The incident has been reported to the Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A Root Cause Analysis Panel is set up to look into the incident. The scope of the investigation will include the related equipment, procedures, operations and other possible contributing factors. A report with proposed recommendations will be submitted to the HAHO within eight weeks. The incident has been reported to the concerned manufacturer of the equipment and the Department of Health for follow-up. The incident has also been reported to the Coroner for follow-up.

Tuen Mun Hospital, Photo source: reference image

Membership of the panel is as follows:

Chairperson:

Dr Carmen Chan

Deputy Chief of Service (Medicine), Queen Mary Hospital

Members:

Ms Chi Chui-yee

Department Operations Manager (Medicine and Geriatrics), Tuen Mun Hospital

Dr Raymond Cheung

Chief Manager (Patient Safety and Risk Management), Hospital Authority

Dr Tam Li-wah

Chief of Service (Medicine and Geriatrics), Kwong Wah Hospital / Tung Wah Group Of Hospitals Wong Tai Sin Hospital

Dr Wong Chi-wing

Consultant (Medicine and Geriatrics), Pok Oi Hospital / Tin Shui Wai Hospital

Mr Bill Wang

Vice-Chairman, Hong Kong Kidney Foundation

Ms Gigi Yiu

Nurse Consultant (Cardiac Care), New Territories East Cluster

Development Bureau imposes regulating action on contractor involved in fatal industrial incident at private worksite in Stanley

A spokesman for the Development Bureau (DEVB) said today (May 15) that the contractor involved in the fatal industrial incident that happened on May 4 at a private worksite in Stanley was under the List of Approved Suppliers of Materials and Specialist Contractors for Public Works.

The DEVB, being the party that procures services for public works, attaches great importance to the site safety performance of all construction sites under the purview of contractors on the List, regardless of whether the sites are public works construction sites or not. The DEVB issued notification to the contractor concerned today to suspend it from tendering for public works contracts in lift, escalator and passenger conveyor installation category with immediate effect pursuant to the regulating regime. The contractor concerned has to conduct an independent safety audit to review its safety management system. Taking cognisance of the outcome of the independent safety audit, the contractor is required to submit an improvement action plan and implement improvement measures, with a view to demonstrating that it has an effective safety management system before the lifting of the suspension from tendering can be considered. The suspension from tendering is not only confined to tender exercises within the period of suspension from tendering, but is also applicable to tender exercises with procedures initiated but not concluded.

The Labour Department is investigating this industrial incident and will handle it in accordance with the law. Subject to the investigation findings, the DEVB may impose further regulating actions on the contractor concerned later on, including extension of the period of suspension from tendering for public works contracts and even removal from the List.

Source: AI-found images