Veteran Hong Kong nurse’s negligence contributed to blunder with premature baby who died after valve on device left closed: inquiry
- Panel finds unopened valve on infusion line was ‘unintentional blind spot’ for nurse as she did not realise medicine was not reaching premature newborn, who later died
- Prince of Wales Hospital in Sha Tin pledges to explore ways to improve sensitivity of alarm system for injection device
A veteran nurse’s negligence contributed to a fatal blunder involving a premature baby with heart problems who died in a Hong Kong hospital after a valve on an infusion line for medicine was not opened, an inquiry has found.
In response to the findings, Prince of Wales Hospital in Sha Tin on Friday pledged to explore ways to improve the sensitivity of the alarm system for the injection device, which was responsible for delivering drugs to the patient.
The nurse, who had more than 20 years of experience and worked in the neonatal intensive care unit for a long time, quit last month for personal reasons.
A hospital-appointed panel released the findings of its investigation two months after the premature newborn died in the intensive care unit 12 hours after a three-way valve controlling the flow of medicine was found to be closed.
It said negligence, among “multiple factors”, was the cause that led to the blunder.
“One of the nurses in charge did not open the valve so the medicine could not reach the infant. We think that inattentional blindness caused such negligence,” said Professor Fok Tai-fai, chairman of the Root Cause Analysis Panel.
“The nurse did look at the valve, but did not realise it was closed.”
Fok said the valve became “an unintentional blind spot” as the child was connected to a number of injection tubes and surrounded by many medical devices and an incubator.
