The following is issued on behalf of the Hospital Authority:

       Regarding an earlier announcement on a sentinel event concerning Percutaneous Coronary Intervention (PCI), the spokesperson for Tuen Mun Hospital (TMH) announced the following investigation findings and recommendations today (January 13):
 
       A 49-year-old male patient presented with symptoms of chest pain and very low blood pressure at the Medicine and Geriatrics Specialist Outpatient Clinic on the morning of October 25 last year. Electrocardiogram and other examinations showed that the patient was suffering from acute myocardial infarction. The patient was in a critical condition and needed to be admitted to the Cardiac Care Unit. PCI was arranged at noon on the same day.
 
       During the operation, when angiography was performed on the right coronary artery (RCA), air embolism of the RCA was noted. The patient's blood pressure remained low and he developed cardiac arrest. Resuscitation was initiated immediately and his condition stabilised afterwards. Doctor thereafter completed the rest of the procedures. While no residual gas was found during the examination subsequent to the operation, the patient was still in a critical condition with persisting low blood pressure. An Extracorporeal Membrane Oxygenation (ECMO) was connected to the patient in the afternoon on the same day and he was subsequently transferred to the Queen Mary Hospital (QMH) for further treatment. The patient has been hospitalised in QMH and in a critical condition until now.
 
       An investigation panel was set up to investigate the causes of the incident and propose recommendations. The investigation panel found out that on the day of the operation, after connecting the necessary catheter and equipment, the computer monitor could not display the aortic pressure waveform as usual. The investigation panel also noted that the nurses had already alerted the doctor to the situation and checked all the equipment again. However, the doctor started the operation before checking was completed. The doctor explained that the operation was commenced as the patient was in critical condition.
 
       In general, if any abnormalities are found such as the blood pressure waveform is not displayed, medical staff should check all equipment again before starting an operation in order to rule out uncertainties, including having air bubbles in the equipment.
 
       The investigation panel has yet to come up with a conclusion for the occurrence of air embolism, but as the equipment used in the operation was in good condition, it is believed that the incident was not due to equipment failure. The investigation panel also noted that the operation record was finished 10 days after the operation, thus the department could not provide a timely follow up in this case.  
 
       In order to avoid the recurrence of similar incidents, the investigation panel has made the following recommendations:
 

• No display of an aortic waveform on the monitor was an important signal. In future, if medical staff encounter similar situation, they should stop and resume operation after finding out the reasons for not displaying the aortic waveform; and

 

• An operation record should be completed as soon as possible after completion of an operation, so that appropriate follow-up treatment can be arranged for the patient.

      After the incident, the Cardiac Unit of TMH imposed mandatory supervision for the doctor concerned on certain treatments and procedures. Medical staff were also reminded to ensure all equipment is normal and well connected before starting an urgent PCI operation in order to safeguard patient safety. The department has also requested that all doctors, after completing an operation, should complete the record as soon as possible so that medical teams can make reference to the record in order to enhance the quality of care provided to the patient.
 
       The hospital accepted the investigation findings and recommendations and the report has been submitted to the Hospital Authority Head Office. The department will refer the case to the Human Resources Division for appropriate follow up action.
 
       The hospital has informed the patient's family of the investigation results and has conveyed a further apology to them. The hospital will continue to keep in touch and provide necessary assistance to the family. The hospital is grateful for the work of the chairman and members of the investigation panel. Membership of the panel is as follows:
 
Chairman
Service Director (Quality & Safety), New Territories West Cluster, Dr Tang Kam-shing

Members
Consultant (Medicine Department), Queen Elizabeth Hospital, Dr Chan Kam-tim
Nurse Consultant (Cardiac Care), New Territories East Cluster, Ms Cheung Heung-wan
Nurse Consultant (Cardiac Care Unit), New Territories West Cluster, Mr Lai Ling-po
Chief Manager (Patient Safety and Risk Management), Hospital Authority, Dr Sin Ngai-chuen

Ends/Friday, January 13, 2017
Issued at HKT 19:12

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