30th November 2023 – (Hong Kong) Caritas Medical Centre announced a sentinel event yesterday, involving the death of a 79-year-old male eye patient. The patient was suspected to have acute intestinal obstruction on 28th November and experienced a decline in oxygen saturation during the transfer from the eye ward to the Intensive Care Unit (ICU). Unfortunately, the patient’s condition rapidly deteriorated, leading to his passing.
Prior to this incident, the patient had undergone peptic ulcer surgery and inguinal hernioplasty. He had also been admitted to the hospital on multiple occasions for treatment related to intestinal obstruction episodes. An eye operation was scheduled for him on the day of the incident. However, in the morning of 28th November, his condition worsened, and he developed desaturation. Oxygen therapy was promptly administered to the patient, and doctors from the Ophthalmology, Surgery, and ICU departments immediately assessed his condition. Based on their evaluation, the patient was suspected to have intestinal obstruction. Due to his deteriorating state, the medical team made the decision to transfer him from the eye ward to the ICU for further treatment.
At approximately 11.10am on 28th November, during the transfer process, the patient experienced desaturation once again. Despite attempts to provide a higher volume of oxygen, his oxygen saturation level continued to decline. The patient arrived at the ICU at 11.15am. It was discovered that the valve of the oxygen cylinder used during the transfer had not been opened. Upon arrival at the ICU, appropriate oxygen supply was immediately arranged for the patient. Healthcare staff performed intubation and cardiopulmonary resuscitation, but his condition continued to deteriorate, and he passed away at 12.50pm on the same day.
Caritas Medical Centre expresses deep concern about the incident and has reported it to the Hospital Authority Head Office. A root cause analysis panel will be established to investigate the event thoroughly and review the patient transfer workflow. The hospital has taken immediate measures to ensure that all medical equipment functions properly during patient transfers to prevent the recurrence of such incidents. Additionally, the incident has been reported to the coroner for further follow-up.
The hospital is profoundly saddened by the patient’s passing. Hospital representatives have met with the patient’s relatives to explain the circumstances surrounding the incident and have extended sincere apologies and condolences. The hospital will maintain communication with the family and provide any necessary assistance during this difficult time.