Experienced medical staff and smart devices should be used when unstable patients are being moved between medical wards, a doctor and a concern group have suggested following the death of an elderly man whose oxygen cylinder was found to be closed during his transfer.
The incident at Caritas Medical Centre on Tuesday involved a 79-year-old patient originally admitted to the ophthalmology ward a day earlier for a cataract operation.
Raymond Lee Wai-chuen, a specialist in critical care medicine, on Friday questioned whether it was appropriate to use medical staff from the ophthalmology department to transfer the patient as they might not have the relevant experience.
“Ophthalmology rarely has any patients who are very unstable … their doctors and nurses rarely have to transfer patients that are very unstable,” he told a radio programme. “Would it be better if more experienced colleagues were involved to handle this?”
At 3am on Tuesday, the patient began to suffer from stomach pains and was given medication, but six hours later staff found his blood pressure and oxygen saturation levels were dropping.
Medical staff suspected he had an intestinal blockage and began to transfer him to the intensive care unit from the ophthalmology ward, but his oxygen levels continued to fall despite the supply being increased.
Staff later found out that the valve of his oxygen cylinder had not been open during his transfer, with the proper supply being arranged promptly, as well as other procedures to help him breathe, but his condition worsened and he died at 12.50pm, the hospital said.
Probe launched into Hong Kong patient’s death after staff find closed oxygen valve
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The patient was transferred by two nurses with more than 10 years of experience and an ophthalmologist, it noted.
Lee said: “They might be very familiar with ophthalmology and their technique is very good, but they deal with these types of unstable patients very rarely and the nurses do not often encounter these cases in their ward … they may start to forget this experience and have less of it.”
In 2018, a similar incident occurred at Queen Elizabeth Hospital where a patient’s ventilation bag was not hooked up to an oxygen cylinder during his transfer. An investigation later concluded that inexperience and a lack of communication between nurses were to blame.
Lee said that while no one solution could prevent similar incidents from occurring, training and staffing were some of the most important factors.
“If there is a lot of staff and they are very experienced, I think there would be less chance of this happening again,” he said.
Patients’ rights advocate Tim Pang Hung-cheong of the Society for Community Organisation said on the same programme that the incident was “unacceptable and unfortunate”.
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Preventing such an incident from happening again would depend on the cause of the current one and whether it was the same as previous cases, he said.
“For departments that have less experience in dealing with these kinds of patients, when they are transferring patients, even if there is a guideline, they may not have the experience to completely follow the guideline and procedures fully,” he said.
To prevent future incidents from happening, more training, drills and guidelines were needed, said Pang, who also suggested using smart devices to detect problems.
Pang said it would be best if medical staff from the intensive care unit were responsible for transferring patients to the department, but it would depend on staffing arrangements.