Medical blunders

Hong Kong public doctor ignored ‘important signal’ for abnormality in heart operation, report says

Patient fighting for his life after air bubbles were found in artery following surgery at Tuen Mun Hospital

PUBLISHED : Saturday, 14 January, 2017, 8:00am
UPDATED : Saturday, 14 January, 2017, 8:00am

A public hospital doctor was judged to have ignored an “important signal” for an abnormality and went ahead with a heart operation on a patient, who is still fighting for his life after air bubbles were found in an artery following the surgery.

A five-member investigation panel also ruled out faulty equipment for the blunder and discovered that the operation record was filled in 10 days after the procedure, delaying follow-up efforts by the Hospital Authority.

A brief history of Hong Kong’s medical blunders

The institution involved, Tuen Mun Hospital, has accepted the findings and apologised to the patient’s family.

The 49-year-old man attended the hospital’s medicine and geriatrics specialist outpatient clinic on October 25 with chest pain and very low blood pressure after suffering a heart attack.

A percutaneous coronary intervention, a non-surgical procedure to open up arteries, was arranged on the same day.

The investigation panel learned that after connecting the catheter and other equipment, the computer monitor failed to display the aortic pressure waveform.

“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 to rule out uncertainties, including having air bubbles in the equipment,” the statement said.

While nurses had already alerted the doctor to the situation and checked all the equipment again, the doctor began the procedures before all checks were completed.

The surgeon has been placed on mandatory supervision for certain treatments and procedures, and may face follow-up action from the authority’s human resources division.

The patient, who has been transferred to Queen Mary Hospital, remains in a critical condition and is surviving on an extracorporeal membrane oxygenation machine.