An “uncommon” false pH test result and an inaccurate medical image were to blame for a blunder at Queen Elizabeth Hospital involving a patient's feeding tube being inserted into his airway and left undetected in June this year, hospital bosses said on Friday. They also said the 61-year-old male patient, who was paralysed, remained under intensive care in a critical state. The hospital in Yau Ma Tei said a nurse replaced the nasogastric tube for the patient in an orthopaedic ward as part of normal procedures on June 16, before another nurse reinserted the apparatus the same evening. But the patient's condition deteriorated around a day later, with doctors finding the tube in his left bronchus. Tang Kam-shing, a doctor who led a root cause analysis panel, said the medics had performed pH tests and an X-ray to check the position of the tube, before proceeding to feed the patient fluids. The sample tested came back acidic, which normally means the nasogastric tube is in the stomach, he added. "In this case, which is a little bit uncommon, the nasogastric tube has gone via the left bronchus into the left pleural space, which is the space between the lungs and the thoracic cage," Tang said. "Because of [the patient's] chest infection, there is some fluid accumulating in the pleural cavity, which is probably infected. When the pleural fluid is probably infected, it will become acidic." Tang, who's also the chief executive of Kwong Wah Hospital, said the houseman checking the X-ray was likely inexperienced. "One of the things that usually the doctor will look at is the tip of the nasogastric tube. Whenever it is in a standard position, then it is one of the factors that we can use to judge whether the nasogastric tube is in the correct space," Tang said. "In this case, because the chest X-ray doesn't show clearly the tip of the nasogastric tube, we think that the doctor involved probably doesn't have enough clinical experience to make sure that the nasogastric tube is indeed in the correct space." As for why the tube was left undetected, Tang said patients normally would show symptoms only after one to two litres had been accumulated in the cavity. The panel suggested reviewing the Hospital Authority's internal guidelines on inserting nasogastric tubes and consider whether to perform an X-ray examination on high-risk patients before feeding them liquids. It also proposed having the attending doctor review previous clinical results in complicated circumstances, as well as coming up with a more standardised medical imaging procedure. Eric Cheung, Queen Elizabeth Hospital's chief executive, apologised to the patient and his family, saying authorities would follow up on the panel's suggestions as soon as possible and provide training and assessment to the medics involved. Asked if the houseman should be held accountable, Cheung said the doctor was part of the team and that "the responsibility ultimately lies with the hospital". The houseman had finished the internship at the orthopaedic unit and officials would follow up according to the panel's report and established procedures, he added.
