ICU patient suffers cardiac arrest due to ventilator misconfiguration at Tuen Mun Hospital

A male patient who was admitted to the Intensive Care Unit (ICU) of Tuen Mun Hospital suffered a cardiac arrest as his ventilator was not being set in normal operating mode by the healthcare staff.

The Hospital announced that the incident happened on Tuesday (Aug 12) as the 48-year-old patient, with acute necrotising pancreatitis complicated by acute kidney injury and respiratory failure, has to be intubated and connected to a mechanical ventilator to assist with his breathing.

After healthcare staff made adjustments to the ventilator and replaced the respiratory circuit at about 7am, the patient developed oxygen desaturation after four minutes, triggering the alarm system. 

The clinical team attended to the patient correspondingly, and the patient suffered a cardiac arrest during the period. The team initiated resuscitation and the patient's heartbeat was restored two minutes later. 

During the resuscitation, it was discovered that the ventilator was not in normal operating mode, and the staff rectified the equipment's operation mode immediately to enable resumption of normal operation.

The patient was conscious and able to respond to the instructions of the healthcare staff after the incident. According to the Computerised Tomography Scan, the clinical team initially determined that the incident had no significant impact on his overall condition. 

The Hospital expressed concern about the incident and met with the patient's family to explain the details. It will offer all possible assistance and follow-up care. 

The patient is still hospitalized in the ICU due to his underlying diseases.

The Tuen Mun Hospital has reported the incident to the Hospital Authority through the Advance Incident Reporting System, and will investigate the reasons why the ventilator was not in normal operating mode.