Hong Kong health care and hospitals

Hong Kong’s North District Hospital to probe patient death after nurse forgets medication

Drugs were placed in a drawer and not handed to 64-year-old patient before he was discharged. He died two weeks later

PUBLISHED : Sunday, 02 September, 2018, 8:04am
UPDATED : Sunday, 02 September, 2018, 8:03am

Hong Kong’s North District Hospital will set up an expert panel to probe the death of a 64-year-old diabetic with pancreatic cancer and a heart condition who died in May after a nurse forgot to hand over his medicine.

The hospital in Sheung Shui on Saturday said the male patient had been admitted to its emergency ward on April 23 for abdominal pain, vomiting and weakness in the lower limbs. He was diagnosed with diabetes and cardiovascular disease and the next day confirmed to also have pancreatic cancer, which had spread to the liver.

After receiving treatment under observation, he was discharged on May 4 with medicine for diabetes, his heart condition and high blood pressure.

“While the patient was waiting to be discharged, the ward nurse put the drugs in a drawer ... and did not hand them to the patient before he left,” a hospital spokesman said.

The man was let go that afternoon without the medication, and staff did not realise their mistake for two weeks.

On May 8, a relative of the patient went to the hospital ward to inquire if the patient had been prescribed any medicine, and was told none had been given.

But on the morning of May 17, ward staff discovered the drug package the nurse had placed inside the drawer.

Later that same day the patient fell unconscious at his home. He was sent to the hospital but was certified dead after resuscitation failed. The case was reported to the coroner.

“According to the death report, the cause of his death is cancer of the pancreas with metastasis,” the hospital spokesman said.

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On Tuesday the same relative informed the hospital that the patient had not been given his discharge medicine, and the facility later found the incident had not been reported to its management.

“The hospital is highly concerned about the incident. An expert panel will be set up to conduct an in-depth investigation ... and to review the workflow with regard to the handling of discharge medication, relatives’ inquiries and the reporting of incidents, and to make recommendations for improvements,” the spokesman said.

Cecilia So Chui-kuen, president of the Hong Kong Nurses General Union, said if a patient required medication after discharge then a doctor would issue a prescription and ask the patient or their family to bring the list to the hospital’s pharmacy to collect the drugs.

She said it was less common to hand out medication on the ward.

William Chui Chun-ming, president of the Society of Hospital Pharmacists, said patients or their carers would get better information on their drugs if collecting them from a hospital pharmacy.

“Pharmacists can offer advice,” Chui said.

Keeping drugs for discharged patients in a drawer on a ward was not common, he added, as the medication could be forgotten.

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Those requiring medicines for heart and blood pressure problems also had to be more cautious in following their regimen, he said.

“Stopping taking these drugs without a doctor’s instruction could lead to a deterioration of the disease,” Chui said.

The hospital spokesman said drug prescriptions were printed on patient discharge summaries. There are notices on wards to remind staff to retrieve discharge medication from the designated drawer.

An electronic patient record system is also available in all wards, allowing staff to check patient medication records and answer related inquiries. Any incidents must be reported to the ward management, the spokesman said.

“The hospital is deeply saddened by this unfortunate incident and would like to extend its sincere apology and condolences to the deceased’s relatives,” he said. “The Patient Relations Office will keep in close communication with the relatives to update them on the investigation results in a timely manner, and will provide them with any assistance as far as feasible.”