Nurse commits ‘unconscious blind spot’ and quits over medical blunder at Prince of Wales Hospital

A nurse who didn’t open the stopcock of an infusion tube when injecting cardiac agent to a newborn baby, who later died, committed an “unconscious blind spot” and has quit her job already, the Prince of Wales Hospital said on Friday. 

The medical blunder occurred at late night on June 13 as medics adjusted the drug infusion rate due to the infant’s persistent hypotension. Yet, the medics later found the stopcock of the infusion tube not opened, preventing the drug from running through. 

Medics immediately resumed the infusion but the infant’s condition deteriorated and the baby died at around 4 pm that day. 

Delivering the investigation results on Friday, former Dean of Faculty of Medicine at Chinese University Fok Tai-fai said the nurse responsible to care for the baby checked all the boxes in accordance with the guidelines and inspected if the infusion tube was blocked. 

Yet, she became distracted as she put too much focus on the drug’s concentration and committed an “unconscious blind spot” – meaning that she saw the unopened three-way valve but accidentally ignored. 

Fok said it was a rare incident. “I have spent years working in the neonatal intensive care unit and this is the first time I see a baby didn’t get the medicine because the stopcock was not opened,” he said. 

Although the machine used to inject the drug to the baby only rang the alarm after 50 minutes, there was nothing wrong with it, Fok said. He added that the design of the three-way valve also made it difficult for medics to identify the direction of the flow of the drug. 

The investigation panel suggested adding a “hand inspection” to check if the drug can run smoothly in the tube and introducing an independent double-checking mechanism to ensure the delivery of high-alert medications to patients. 

The Hospital Authority is also mulling possible ways to shorten the time needed to trigger the alarm and will explore a better design for the three-way valve with the manufacturers. 

The hospital’s chief executive Chung Kin-lai said the two doctors tried their best to improvise and save the baby. The two doctors and another nurse have resumed their duties. As for the nurse responsible for changing the drug for the baby, she has quit in July due to overwhelming pressure. 

Chung again apologized to the baby’s parents and the public. Chung also said the parents were thankful for effort of the investigation panel during their meeting yesterday. 

Chung said the hospital will provide support to the parents if they need any further assistance. 

Previously: 

- Equipment blunder sees premature baby die at Prince of Wales Hospital

- Baby tragedy probed

- Prince of Wales Hospital establishes investigation committee over latest medical blunder; relevant medics on leave