Prince of Wales Hospital announces sentinel event
The following is issued on behalf of the Hospital Authority.
The spokesperson for Prince of Wales Hospital (PWH) announces a sentinel event today (September 18):
Prince of Wales Hospital, Photo by Bastille Post
A 54-year-old male patient, who had a history of dementia and stroke, and required a puree diet, was sent to the Accident and Emergency Department of PWH by ambulance on the morning of September 16 due to deteriorated mental status. He was admitted to a medical ward for treatment. During feeding the patient began choking and developed a cardiac arrest, and subsequently succumbed late that same night.
The hospital is very concerned about the incident and immediately launched an investigation. Preliminary findings indicated that upon admission, the patient did not carry any identification document, and a "pseudo identifier" was generated for registration. According to the patient's clinical condition, the attending doctor gave a "diet as tolerated" order for nursing staff to follow up. However, as the hospital's Dietary and Catering Management System defaults to arrange a regular meal for patients registered under a "pseudo identifier", and a nursing staff member did not complete checking the patient's previous diet records to adjust the diet order, a regular meal was served to the patient that night.
At around 6.40pm, the patient was found feeling unwell when a patient care assistant (PCA) began feeding the patient a regular meal. The PCA immediately stopped the feeding and sought help from a nursing staff member. Upon examination, the nursing staff member noted a drop in the patient's blood oxygen saturation level, and immediately called clinicians to suction the patient and administer oxygen therapy. Clinicians from the Ear, Nose and Throat Department and the Intensive Care Unit were also called to assist in removing the foreign object in the patient's airway. The patient developed a cardiac arrest during the process, and his condition continued to deteriorate. He succumbed late that same night. Upon reviewing the patient's history after the incident, the hospital found that the patient had been frequently hospitalised before due to underlying diseases. Following speech therapy assessment, a puree diet was recommended for the patient due to dysphagia.
The hospital is deeply saddened by the patient's passing, and has met with the patient's family to explain the incident, and extended its sincere apologies and condolences. The hospital will keep close communication with the family to render necessary assistance.
The hospital has devised immediate measures, including reminding healthcare staff to thoroughly assess patients' clinical conditions and diet orders before making meal arrangements, and reviewing the default meal setting of the system. The nursing staff member and PCA concerned have been temporarily arranged for non-clinical duties.
The hospital has reported the incident to the Hospital Authority Head Office via the Advance Incident Reporting System. A root cause analysis panel has been appointed to review the incident thoroughly. The investigation and recommended improvement measures will be completed within eight weeks. The incident has also been referred to the Coroner for follow-up.
Prince of Wales Hospital, Photo source: reference image
The Root Cause Analysis Panel members are as follows:
Chairperson:
Dr Kenny Yuen
Hospital Chief Executive, Tseung Kwan O Hospital and Haven of Hope Hospital
Members:
Professor Chair Sek-ying
Vice-Director of Research, the Nethersole School of Nursing, Faculty of Medicine, the Chinese University of Hong Kong
Ms Moon Chan
Manager (Patient Safety & Risk Management), the Hospital Authority
Dr Chan Tak-yeung
Deputy Chief of Service (Medicine & Geriatrics), Kwong Wah Hospital
Ms Cheung Shuk-yee
General Manager (Nursing), Shatin Hospital
Ms Lee Lai-shan
Department Operations Manager (Medicine), Tseung Kwan O Hospital
Dr Wong Wing-yin
Consultant (Medicine & Geriatrics), Caritas Medical Centre
Dr Linda Yu
Service Director (Quality and Safety), New Territories East Cluster
Prince of Wales Hospital, Photo source: reference image
