Pamela Youde Nethersole Eastern Hospital announces a sentinel event

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17th October 2020 – (Hong Kong)   An 83-year-old male patient with lymphoma was admitted to the Medical Ward at Pamela Youde Nethersole Eastern Hospital (PYNEH) on September 30 due to shortness of breath. He was transferred to the Intensive Care Unit (ICU) on 5th October for acute respiratory failure, and diagnosed with pneumonia. Presented with conditions including Hyperkalemia, medication was prescribed.
      
 Patient’s vital signs gradually turned stable on 14th October and was discharged to the Medical Ward for further treatment in the same afternoon, including the monitoring and treatment of Hyperkalemia. Staff of the Medical Ward performed blood tests for the patient at 9pm on 14th October and at 3am on 15th October respectively. Test results showed repeated high level of serum potassium. Prescribed medication and close monitoring of Hyperkalemia were required. 
      
 At 6.28pm on 15th October, the patient was found unconscious by an ICU nurse during a regular follow-up ward round. Electrocardiogram wave was shown flattened. Cardiopulmonary resuscitation for the patient was performed immediately but in vain. The patient passed away at 7.40pm. An initial review has suggested room for improvements in the monitoring and treatment of Hyperkalemia for the patient. PYNEH is very concerned about the incident. It has been reported to the Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A Root Cause Analysis Panel will be set up to investigate the incident and recommend enhancement measures.  The report will be submitted to the HAHO in eight weeks. The incident has also been reported to the coroner for further investigation.
      
 The hospital had expressed deep condolences and explained the treatment process to the patient’s family yesterday. The hospital will continue to closely communicate with the patient’s family to provide necessary assistance.

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