Patient dies after tube misplaced in airway

PUBLISHED : Saturday, 07 August, 2010, 12:00am
UPDATED : Saturday, 07 August, 2010, 12:00am

A 75-year-old pneumonia patient died after a nurse inserted a tube into an airway instead of his stomach.

The tube was discovered in a chest X-ray a day after it was inserted.

A spokesman for St John Hospital in Cheung Chau, where the man died, expressed condolences to his family members.

The man, suffering from pneumonia and bedsores, was admitted to the hospital on July 23. He was bedridden and had difficulty swallowing.

He began to be fed through a nasogastric tube three days after admission and was also given oxygen to maintain the supply in his blood.

A nurse removed his old tube and inserted a new one on Monday but accidentally inserted it into his bronchus. The patient's vital signs were unchanged when the mistake was discovered the following day, but his condition deteriorated, and he was certified dead at 10pm that day.

Dr Anthony Yim Ping-chuen, a cardiothoracic surgery specialist, said medical staff should make sure that such tubes are really inserted into the stomach before feeding.

'It would cause very serious pneumonia if nutrient milk was fed into the lungs. The patient would have breathing difficulty, and his blood oxygen level would be low,' he said.

A spokesman from the Hospital Authority said it was very concerned about the incident and would form a panel to investigate.

The investigation was expected to be completed within six to eight weeks.

'If human factors were involved in the incident, appropriate action will be taken according to the human resources policy,' the spokesman said.