A patient died after a tube became disconnected from a non-invasive ventilator without an alarm sounding, according to the Hospital Authority’s second-quarter risk bulletin. An investigation found the equipment’s alarm settings had been changed during maintenance, and staff did not discover the problem in time.
The Authority recorded 29 medical risk events in the quarter: eight risk-alert events and 21 medication events. In response to the ventilator case, it recommended more staff training in operating ventilators, standard procedures and improved equipment monitoring, including consideration of a central monitoring system.
A separate medication error involved a patient with lymphoma and pneumonia who was agitated and had bitten through a high-flow nasal cannula. A doctor prescribed 3 milligrams of midazolam. A ward staff member prepared a syringe containing 15 millilitres and told an intern to inject only 3 millilitres, but after a communication failure the intern administered the full syringe. The patient received five times the prescribed amount and went into shock. The bulletin recommended preparing syringes with only the prescribed amount and pausing to clarify any uncertainty before treatment.
The bulletin also described a patient with a mechanical heart valve who was taking warfarin and had been admitted for anticoagulation treatment around a planned colonoscopy. After the procedure, the team stopped daily INR blood tests, which monitor clotting, too early. The patient left before the bridging treatment was complete and without a latest INR test. Two days later, the patient attended the emergency department with an acute stroke. The Authority advised teams to follow treatment plans, record decisions and discussions with family, and maintain communication and continuity of care.
In another case, gauze was found in a patient’s surgical wound a year after an operation following a stroke. It was removed in a further operation, and examination found no complications.
The bulletin also tells staff to review patients’ health and dietary histories and check that they can swallow safely before arranging meals. If there is any doubt, staff should hold off on serving food, notify the medical team and refer the patient for a swallowing assessment.