Premature baby dies at Hong Kong hospital after equipment error delays infusion; investigation pledged
Hong Kong Free Press
A premature baby has died at a Hong Kong government hospital after an error related to the equipment delayed an infusion for 50 minutes, prompting authorities to apologise and promise an investigation.
The baby was born on June 12 after 28 weeks with congenital heart problems and other issues. The infant needed ventilator support and an infusion of inotropes drugs and was admitted to the Neonatal Intensive Care Centre at The Prince of Wales Hospital.
As the infant displayed persistent hypotension, medical staff adjusted the infusion at around 3am on Tuesday.
“An alarm of the infusion equipment was triggered at around 3.50am. Health care staff immediately checked the equipment and found that the stopcock of the infusion tube was not opened, which obstructed the drug infusion, ” a hospital spokesperson said in a statement.
The baby died at 4pm Tuesday.
The hospital said it has set up a Root Cause Analysis Panel to investigate the incident, and apologised to the family. The case has been reported to the Hospital Authority, the body that manages all government hospitals, and referred to the Coroner.
Cardiologist Bernard Wong said on NowTV that the incident might be “one tragic incident caused by multiple errors” as equipment in the centre was supposed to be very sensitive.
Wong said he believed it was abnormal for the alarm not to go off for 50 minutes and the alarm might have been faulty. “The nurses might have been very busy and turned to other tasks once the infusion was set. It was too late when they returned to check.”
The cardiologist said that due to a manpower shortage in government hospitals, it was not unusual for staff to forgot to open the stopcocks of infusion tubes. However, medics could usually detect and correct such errors in a timely fashion without causing fatal accidents.
Shortage of Medics
The accident came amid rising concern over the city’s shortage of doctors, nurses and support staff after a wave of emigration following the 2019 protests and unrest.
The turnover rate of nurses in the year 2021/22 rose to 9.4 per cent , a significant increase over 5.8 per cent the previous year, according to a Hospital Authority document cited by Ming Pao.
Exit interviews at Queen Elizabeth Hospital showed that emigration was the main reason, cited in 39 per cent of all cases.
Some 1,247 doctors left government hospitals over the past three years, with only 191 of them retirees, Health Secretary Lo Chung-mau told legislators in March.
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