Findings needed to avoid more anguish

I am saddened to hear that a premature newborn suffering from congenital heart problems died after the stopcock of an infusion tube delivering the required medicine reportedly had not been opened.

In light of the infant's small size, the drip rate had to be set at an extremely slow rate, reportedly 0.3 milliliter per hour, and to be gradually increased to 0.7 milliliter per hour.

Every time a medical blunder occurs, the Hospital Authority would announce an investigation. It is no exception this time. As it confirmed the incident in a press release, the authority promised there would be a thorough investigation.

According to past experience, it is expected that it would also announce the results when the investigation is completed.

With that being said, it is only hoped that the authority would not wait to reveal the findings until after the case has been heard by the coroner's court, to which the incident has already been referred.

Investigation findings can be very useful in preventing incidents of similar nature from occurring again.

Remember that it had not been uncommon to hear mix-ups involving either patient's identity or medication in the long past. Since then, it has become a standard procedure to double confirm the identity or require a second nurse to confirm the correct medication being given out.

More often than not, medical blunders are related to procedure. And in this particular case, an intensive care nurse and a rather common medical equipment were involved.

According to media reports, the stopcock of the infusion tube had not been opened. An unanswered questions is: whether the ICU nurse had forgotten to open the stopcock at all or the drip did not pass through due to the extremely tiny adjustment that had to be set.

There still appears to be a doubt on that.

It is far too often to be too ready to pass the blame to staff shortage for blunders, which, to me, is all but just nonsense. Staff shortage cannot clear someone of a mistake.

If the nurse was found to have forgotten to open the stopcock at all this would be a case of unacceptable negligence.

If the nurse had adjusted the stopcock but only that the valve opening was too small for the drip to pass through, this could be corrected by improved procedure.

In light of the incident, it may be desirable to make it a standard requirement for a second nurse to confirm the adjustment made when dealing with delicate steps like that. This would have prevented the incident from happening in either situation.

There is also a further question to answer: the equipment alarm did not go off until 50 minutes later. Why was that?

According to a pediatric doctor interviewed by the media, the alarm should have gone off a lot sooner in the event that a stopcock had not been opened.

It will be of absolute importance for the investigation to find out the exact cause of the blunder so that the correct solution can be prescribed.