Patient had stroke after tube error

PUBLISHED : Saturday, 27 November, 2010, 12:00am
UPDATED : Saturday, 27 November, 2010, 12:00am

A 70-year-old patient suffered an acute stroke after a tube was wrongly removed from a vein, the Hospital Authority's latest list of errors shows.

A junior doctor had instructed the patient to sit still while he removed a jugular catheter when he should have been lying down or with head down, the authority publication Risk Alert says.

It was inserted during dialysis to clean the patient's blood.

Gauze was used to control the bleeding but soon afterwards the patient felt dizziness, numbness and left-side weakness. A scan found tiny air pockets in both carotid arteries. Oxygen was given to the patient the same day and he recovered and was later discharged.

The publication attributed the error to the inexperience of the doctor and suggested developing a guideline on the removal of tubes, and better supervision of junior staff.

In another case, doctors treating a patient suffering pleural effusion - a build-up of fluid in the space around the lungs - tried to suck fluid from the wrong side, not realising their error until only air came out. An authority spokesman refused to reveal if the staff concerned had been punished.

The publication also identified four incidents involving wrong administration or doses of vasopressers - drugs that raise blood pressure by constricting the vessels - and inotropes, which affect the action of heart muscles.

In two of the cases, nurses wrongly injected 200 times and 10 times the required dosage of adrenaline to two patients. The patients developed quickened heart rates, headache and vomiting.