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The following is issued on behalf of the Hospital Authority:
The spokesperson for North District Hospital (NDH) made the following announcement today (November 20) on a serious untoward event:
An 84-year-old female patient, suffering from malignant Melanoma was transferred to the surgical ward of NDH on November 18 from the Accident and Emergency Department of Alice Ho Miu Ling Nethersole Hospital due to abdominal pain. Based on radiographic imaging results, perforated viscus was diagnosed. In view of the terminal nature of her illness, the patient's relatives opted for palliative care.
After admission to the surgical ward, the patient started receiving intravenous fluid for hydration and nutritional supplement. To help relieve her severe pain, morphine infusion was additionally prescribed at 3.3ml/hour to the patient at 11.45am for pain control. At around 2pm, the bag of intravenous nutritional fluid was finished. The ward nurse assigned a student nurse to replace a new bag of intravenous fluid. After placing the bag of intravenous fluid on the pod, the student nurse had erroneously adjusted the infusion device of the morphine infusion to 83ml/hour.
After around an hour, the ward nurse was alerted by the alarm of the morphine infusion pump which indicated the fluid bag was finished. The nurse had checked that a total of 83ml of fluid with 28mg of morphine had been given to the patient. At that time, the patient's respiratory rate was 13 breaths/minute and oxygen saturation was 95 per cent at the normal level. Her blood pressure remained low but the same as baseline. The case doctor and the patient's relatives were notified immediately while the patient's condition was closely monitored. The incident was also explained to the patient's family with apology extended.
Around five hours following the incident, the patient succumbed at 7.29pm on November 18. NDH expresses its deepest condolences to the family for the death of the patient and continues to closely communicate with the family to provide all the necessary assistance. The case has been referred to the Coroner for follow-up. The incident has also been reported to the Hospital Authority Head Office (HAHO) through the Advance Incident Reporting System. An investigation panel will be set up to investigate the incident. The investigation report will be submitted to HAHO in eight weeks. Recommendations will be made to enhance the supervision and delivery of patient care to prevent recurrence of similar incident.
Ends/Friday, November 20, 2015
Issued at HKT 20:33
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