Inexperience and poor communication led to oxygen blunder at Hong Kong’s Queen Elizabeth Hospital, report finds
- Report into transfer to intensive care finds man’s ventilator was not hooked up to any oxygen
Inexperience and a lack of communication between nurses at a Hong Kong public hospital led to a patient ending up with a ventilation bag not hooked up to an oxygen cylinder, an investigation has concluded.
The man was admitted to Queen Elizabeth Hospital in Yau Ma Tei on September 27 with severe acute pneumonia, and later developed respiratory failure.
He was connected to a ventilator for breathing and was transferred to intensive care the following night as his condition had not improved, a Hospital Authority spokesman said in a statement on Friday.
Staff later found that the self-inflating ventilation bag used during the transfer had not been connected to an oxygen cylinder. The man died on September 30.
According to the findings of an investigation report, ward staff had had to resuscitate another critically ill patient at the same time as the transfer.
But the nurses involved were relatively inexperienced in handling such an emergency, the report said.
It added that, because of a lack of communication among the staff during the transfer, the equipment and the patient’s documentation were not properly checked.
But it noted that even without the blunders the man might still not have survived, given his rapidly deteriorating condition.
The panel that wrote the report asserted the importance of various checks, including of whether all medical equipment and documentation is prepared before transferring critically ill patients.
Communication during such transfers should also be enhanced, the report said.
The authority accepted the panel’s findings, and said it had explained them to the patient’s family.