Caritas Medical Centre to enhance training after oxygen blunder leads to patient death

Caritas Medical Centre (CMC) will enhance the healthcare personnel's training and role delineation after a medical blunder happened last year that resulted in the death of a 79-year-old patient as the staff failed to turn on the oxygen valve.

The victim was admitted to the CMC Ophthalmology ward in November last year for a scheduled surgery. He was suspected of having an acute intestinal obstruction and developed bacteremia subsequently, and he had to be escorted to the intensive care unit for further treatment. However, the healthcare team discovered that the valve of the oxygen cylinder had not been turned on during the transport process, and the 79-year-old succumbed on the same day.

The Root Cause Analysis Panel, which was formed to investigate the incident, announced the report on Tuesday stating there were multiple factors attributed to the event, including unclear role delineation of preparing monitoring equipment and oxygen cylinder before the transportation of critically ill patients; inadequate clinical handover before departure; and the oxygen cylinder concerned had a potential space between oxygen valve and the oxygen flow adjustment knob.

The panel recommended strengthening the refresher in-service training for the healthcare professionals, while the role delineation of transport team members should be specified in both the preparation phase and during the transport procedure.

It added that the clinical handover and documentation should be emphasized in the whole transport of critically ill patient process with the use of transportation forms and checklists, and crew resources management training should be introduced to enhance communication in handling critically ill patients.

As for handling the oxygen cylinders, the panel suggested informing the potential pitfalls related to the design and the use of the oxygen cylinder Safety team Hospital Authority Head Office while putting up educational posters about the proper use of oxygen cylinders and attaching cue cards to each oxygen cylinder.

CMC said it has met with family members to explain the report's findings and once again apologized and expressed its deep condolences for the incident.