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The following is issued on behalf of the Hospital Authority:
The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (June 11) on a blood bag storage incident:
A nursing staff of the Operating Theatre at QEH discovered the malfunction of the blood refrigerator on the second floor of the Operating Theatre in early hours yesterday (June 10) during regular inspection. The incident was immediately reported to the hospital blood bank and the blood refrigerator was immediately checked by the department concerned. It was suspected that the short circuit of the compressor in the refrigerator led to the malfunction. A total of 68 affected bags of blood had been returned to the hospital blood bank for quarantine and were confirmed not suitable for transfusion. The operation of another blood refrigerator located on the fourth floor of the Operating Theatre continued. Patient service at QEH was not affected.
The staff in the Operating Theatre immediately checked the temperature graph attached on the blood refrigerator and confirmed that the temperature of the blood refrigerator started to increase from 4pm onwards on June 9 and exceeded the suitable temperature of storing blood (2 degrees to 6 degrees Centigrade), and reached 12 to 13 degrees Centigrade.
In general, the blood refrigerator all along has a double alarm system to safeguard its operation. A built-in alarm of the refrigerator will be activated when its operation is abnormal. Meanwhile, an independent monitoring system is installed in the blood refrigerator, which diverts alarm to the 24-hour nurse station in the Operating Theatre. The duty staff could then be alerted to handle the incident immediately. According to initial investigation of the incident by QEH, the remote alarm connected to the nurse station has been abnormally connected and therefore the alarm was not activated.
The nurse checked the blood transfusion record at once and it was found that a pregnant patient received 2 bags of affected blood at about 10pm on June 9 after giving birth to a baby. Clinicians conducted check-up for the patient and arranged various blood and bacterial infection tests. The hospital met with her and her family to explain the details of the incident and apologised to them. As the 2 blood bags were processed in a closed system, the possibility of the patient getting affected is low. She is now in stable condition and antibiotics were prescribed during her delivery process. The hospital will closely monitor her situation.
The hospital management expresses deep apology to the public and the blood donors. QEH is very concerned about the incident and the Electrical and Mechanical Services Department (EMSD) has immediately checked the alarm systems of all critical equipments. The hospital has reminded their staff to stay alert on the alarm systems of all critical equipments to prevent the happenings of similar incidents again.
The incident has been reported to the hospital management and Hospital Authority Head Office (HAHO) via "Advanced Incident Reporting System". The hospital will seriously follow up the incident with EMSD to investigate into the reason of malfunction of the alarm system. The investigation will be completed in six to eight weeks and the report will be submitted to the HAHO.
Ends/Monday, June 11, 2012
Issued at HKT 22:54
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