********************************************************
The following is issued on behalf of the Hospital Authority:
The spokesman for Princess Margaret Hospital (PMH) today (August 2) announced the findings of the Investigation Panel Report on a sentinel event that happened on May 26, 2013.
A 57-year-old female patient had been under convalescent care in Lai King Block at PMH since September 2012. The patient suffered from a rare motor neuron disease at an advanced stage, complicated by respiratory failure, and required oxygen therapy via a facial mask of a non-invasive ventilation system ― Bi-level Positive Airway Pressure (BiPAP). On May 26, 2013, two experienced nurses transported the patient to another cubicle in the same ward to allow cleaning and disinfection. Based on the fact that the patient was stable in clinical condition and had a normal level of oxygen saturation, and the bed transport duration was expected to be short, the nurses judged that the patient could tolerate the short period of time without oxygen therapy. The patient's condition deteriorated during the transport and she succumbed on the same day.
PMH set up an independent Investigation Panel to investigate the case. The investigation report showed that the two nurses had respectively nine years and over nine years of experience. They had received training on the use of BiPAP and had experience in caring for such patients. They were also aware of the established guidelines and procedures on oxygen therapy and transportation of critically ill patients. In general, the condition of patients on oxygen therapy via a BiPAP may vary. However, most patients can stop using the BiPAP to perform simple daily activities such as eating and bathing.
According to the investigation result, the patient had temporarily stopped using oxygen therapy to undergo face cleaning and an inhalation of a dose of medication on the morning of the event. Besides that, the patient was stable in clinical condition and had a normal level of oxygen saturation. All these factors had led to the nurses to over-estimate the patient's tolerance of the discontinuation of oxygen therapy during the bed transport. The Panel considered that oxygen therapy should be continued for patients of such an advanced nature during bed transport, even if the transportation is short. The oxygen saturation status should also be monitored.
The Panel was of the opinion that the event was not only due to the nurses' judgment; there were other contributory factors. Nurses working in Lai King Block have relatively few chances to use BiPAP, which contributed to the over-estimation in their judgment. As the nurses working in Lai King Block still need to take care of similar patients, the Panel considered that staff training on the use of BiPAP should be reinforced and their vigilance should be raised.
Based on the findings, the Panel made the following recommendations:
1. To enhance staff education and training
It is advisable to review the adequacy of education and training on the use of BiPAP to ensure that health care workers in convalescent wards possess adequate knowledge of the related procedures, which will raise their vigilance.
2. To reinforce the promulgation of the guidelines on transport of critically ill patients
The Hospital Authority has guidelines on transporting critically ill patients. Promulgation of such guidelines should be reinforced and staff should be reminded to closely observe the guidelines when transporting critically ill patients even a short distance.
3. To extend the corporate guidelines for the use of BiPAP
At present, guidelines for the use of BiPAP are developed for patients with Chronic Obstructive Airway Disease. The panel recommended extending the guidelines to cover more conditions such as respiratory failure secondary to motor neuron disease as in this case. The guidelines should also include measures to be taken when the patient is temporarily taken off BiPAP and during patient transfer within the hospital for treatment or investigation needs.
The Hospital Chief Executive of PMH, Dr Nancy Tung, said that the hospital had accepted the Investigation Report and will implement the Panel's recommendations. After the event, the hospital strengthened staff education and training on the use of non-invasive ventilation by organising a seminar and four in-house training sessions for the nurses in Lai King Block. The hospital had also met the deceased's family to explain details of the report and expressed sincere apologies and condolences again. The case was referred to the Coroner for follow up.
The hospital has submitted the report to the Hospital Authority Head Office and will follow up on the case in accordance with established human resources procedures. The concerned nurses said they felt very sorry and sad about the patient's death. They had been on leave for a period of time after the event and are now back at work under supervision after re-training.
Dr Tung also expressed her heartfelt gratitude to the Chairman and members of the Investigation Panel for their professional advice in conducting the investigation.
Members of the Investigation Panel include:
Chairman:
Dr Chan Hok-sum
Sub-specialty Group (Respiratory Medicine) Convener
Central Co-ordinating Committee (Medicine)
Hospital Authority
Members:
Mr Chan How-chi
Hospital Governing Committee
Kwai Chung & Princess Margaret Hospitals
Ms Lit Pik-kee
Specialty Advisory Group (Respiratory Nursing) Convener
Hospital Authority
Ms Katherine Pang
Manager (Patient Safety & Risk Management)
Hospital Authority
Dr Tony Mak
Service Director (Quality & Safety)
Kowloon West Cluster
Ends/Friday, August 2, 2013
Issued at HKT 17:54
NNNN