Doctor who wrongly filled balloon with gas before it burst inside HK woman’s anus ‘may have been distracted’

18-Feb-2019 Intellasia | South China Morning Post | 6:00 AM Print This Post

A doctor who wrongly filled a balloon with gas before inserting it into an octogenarian patient’s anus, causing the balloon to burst and injure her rectum, may have done so because of the busy and distracting environment, according to an investigation report released on Friday.

Pamela Youde Nethersole Eastern Hospital, where the blunder happened, apologised again for the error two months ago, and accepted the probe’s findings.

The 86-year-old patient had a virtual colonoscopy at the Chai Wan hospital on December 7, 2018. The procedure uses external scanners and requires gas pumped into the colon to inflate it and give a better image.

The Hospital Authority investigation found that a small balloon placed in the woman’s anus to stop any gas leaking out was accidentally filled with the gas itself and then burst, causing the injured rectum. It was meant to have been filled with water.

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The authority found that the outlets for the gas and for the water were both blue, so the radiologist might have used the wrong one to fill the balloon.

The investigation panel said the radiologist might have been distracted.

“The radiologist could have been distracted by the busy environment in the CT suite on the day amid urgent CT requests from multiple wards, and therefore identified the wrong port,” the panel added.

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It recommended that staff follow the supplier’s instructions or user manual as far as possible, and make themselves aware of the similarly coloured but crucially different outlets.

The hospital said it accepted the panel’s findings and recommendations, had explained them to the patient’s family, and apologised again.

After the accident, an emergency operation was carried out to fix the damage. The woman remained stable and was sent home, having recovered, on December 22, 2018. The hospital apologised at the time as well.


Category: Hong Kong

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