Baby tragedy probed

A premature baby with heart problems has died at Prince of Wales Hospital after the stopcock of a tube for lifesaving medicine remained inadvertently closed.

The Hospital Authority is struggling to explain how the medical blunder happened.

Prince of Wales Hospital in Sha Tin disclosed the Tuesday blunder only near midnight on Wednesday.

Secretary for Health Lo Chung-mau said yesterday he was saddened about the death, adding that Hospital Authority officials will explain the incident later.

Prince of Wales said the newborn was delivered on Monday after less than 28 weeks of gestation.

Due to the premature birth and congenital heart problems, the baby had to be put on a ventilator in intensive care and received an infusion of inotropes to help the heartbeat.

As the baby suffered from persistent hypotension - low blood pressure - the medical staff adjusted the drug infusion rate at around 3am on Tuesday, increasing the rate from 0.3 milliliters an hour to 0.7ml an hour.

However, the stopcock of the infusion tube was not opened, preventing the drug from running through to the infant. But medics did not find out about the situation for nearly an hour until an alarm in the equipment was triggered at 3.50am.

The hospital said staff immediately resumed the infusion, but the infant's condition continued to deteriorate. The baby died at about 4pm on the same day.

The case has been reported to the Hospital Authority head office and referred to the coroner's court.

Prince of Wales said it will also set up a panel to investigate the incident. It was concerned about the incident and apologized to the infant's family.

It said it had adopted immediate measures to prevent similar incidents, including reminding staff to be vigilant when performing drug infusion with newborns.

Cardiologist Bernard Wong Bun-lap, asked to comment on the incident, said the case might involve both human error and equipment failure as the infusion equipment should have send alarms within minutes if the stopcock was closed.

"It's abnormal that the alarm of the equipment was not triggered for 50 minutes," Wong said. "It's possible that nurses were busy and left immediately after setting up the infusion and it was too late when they returned to check the baby." Wong also said public hospitals are suffering from a manpower shortage and it is common for nurses to sometimes forget to open the stopcock of the infusion tubes.

But medics would notice the situation most of the time so it would not lead to fatal accidents.

Pediatrician Tong Kai-sing thought the incident was not caused by the insensitivity of the equipment.

The machine would only give alarms when its pressure reached a certain level, he said. As the doctor prescribed only a small amount of drugs for the baby, it would take a long time for the alarm to go off.

Tong also said the infant was receiving infusion through a three-way lock tube, meaning the baby was also receiving other drugs at the same time.

He added that medics should make sure drugs run through the tube by themselves instead of relying on machines.

"Machines are not reliable; humans are the most trustworthy," he said.

Another pediatrician, Henry Yeung Chiu-fat, said premature babies who require inotropes infusion are usually in a dangerous situation so continuous infusion is crucial.

Pediatrician Alfred Tam Yat-cheung said infants with low blood pressure may be in a life-threatening situation just 10 minutes after they have stopped receiving cardiotonic drugs.

The chairman of Hong Kong Patients' Voices, Alex Lam Chi-yau, said the incident was likely caused by human negligence.

"The incident could have been avoided as it could have been detected by the equipment," he said.

"Medics should also observe whether the infusion worked. It's unacceptable that the flaw was discovered only after an hour."

Lam said medics involved in the case should be transferred to other positions until the investigation is over.

It is understood that at least two nurses were involved in the incident as the infusion required cross-checking.

Sources said nurses closed the stopcock of the infusion tube to replace medication but forgot to open it again. A team studying the infant's hypertension did not notice the stopcock remained closed.

Pediatrician Fong Nai-chung from Princess Margaret Hospital said public hospitals observe strict procedures when providing medication to patients, including two staff members verifying the drugs and patients' information.

He added that medics at intensive care units check on patients' condition - including their pulse, blood pressure and infusion progress - every hour.

wallis.wang@singtaonewscorp.com

Editorial: Findings needed to avoid more anguish