Queen Elizabeth Hospital (QEH) announced a sentinel event involving a 68-year-old male patient with severe pneumonia and multiple organ failure yesterday (August 21). The incident has also been reported to the hospital management and Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System.
The patient was admitted to the Intensive Care Unit of QEH on March 17 for treatment. Subsequently on April 6 and 8, emergency operations of bowel resection and exteriorsation were conducted respectively to deal with his massive bowel ischemia. After the operation, the patient had short gut syndrome and therefore was arranged to have total parenteral nutrition via catheter continuously to transfuse nutrition. During his hospitalisation, the condition of the patient has been gradually improving.
It was until August 18 12:30pm when the patient's condition deteriorated suddenly with paralysis on the left side of his body. The hospital immediately conducted resuscitation and arranged multi-disciplinary consultation from the Intensive Care Unit, Neurology, Toxicology of the Accident and Emergency Department, and Radiology and Imaging for the patient.
Additionally, an urgent CT scan was arranged. Results revealed there were tiny air bubbles in the patient's right brain, which was compatible with clinical acute stroke symptoms over the left side of his body. As the air bubbles found in the patient's brain were abnormal, the hospital classified the case as a sentinel event.
In the evening of the same day, the patient was transferred to the Intensive Care Unit of QEH for further treatment. At 9.30pm, escorted by doctors, the patient was transferred to the Recompression Treatment Centre on Stonecutters Island for Hyperbaric Oxygen Therapy.
In the afternoon of the following day, the patient was transferred to the Intensive Care Unit at Pamela Youde Nethersole Eastern Hospital (PYNEH) for treatment. The condition of the patient is now serious.
Spokesperson for QEH said they will closely monitor the patient and provide appropriate treatment in collaboration with the medical team of PYNEH. They have also explained to the patient's family the incident and the follow-up treatment plan.
After initial investigation, QEH confirmed that the medical team had provided prompt clinical treatment to the patient. The hospital will investigate the reason of the occurrence of air bubbles in the patient's brain. A Root Cause Analysis Panel will be formed and the report is to be submitted to the HAHO in eight weeks. MIMS
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