The Kaohsiung Department of Health yesterday fined Kaohsiung Municipal Min-Sheng Hospital NT$500,0000 for misidentifying two patients and consequently causing one of them to undergo the wrong surgery last week.
The hospital’s director Yen Chia-chi (顏家祺) was suspended from his duties.
The surgeon who was scheduled to operate on the patient was given a major demerit and is subject to subsequent disciplinary actions.
Photo: Taipei Times
Demerits were given to the anesthesiologist, the nurse in the operation room, the nurse in the ward and the worker who helped transfer the patient from the ward to the operation room for having failed to verify the patient’s identity.
Meanwhile, the hospital’s deputy medical director, surgical department director, nursing department director, operating room director, the head nurse of the operating room and the head nurse of the ward were all reprimanded.
The hospital was fined NT$500,000 for contravening Article 108 of the Medical Care Act (醫療法), which punishes medical care institutions for negligence of medical practice management resulting in injury or death to the patient, the department said.
The hospital should analyze the fundamental causes of this major medical accident, propose improvement plans and report to the department, as per the Medical Accident Prevention and Dispute Resolution Act (醫療事故預防及爭議處理法), the agency said.
A source familiar with the matter told the Liberty Times (the Taipei Times’ sister newspaper) that the two male patients, surnamed Huang (黃) and Chang (張), shared the same ward.
Huang, who had a stroke, was hospitalized for having low blood pressure, while Chang was scheduled to undergo chest drainage surgery on Thursday last week, the source said.
However, Huang was brought to the operation room instead. The error was not discovered until the nurse in the ward was scheduled to administer medication to Huang, the source said.
Hospital deputy director Chang Ke (張科) said that the incident happened at 8am, which was the time at which day shift personnel replaced the night shift workers.
“The patient was scheduled to have a chest drainage surgery because of pustules in the chest, so the attending physician was preparing to drill a hole in the patient’s chest to put in the tube. However, the physician sensed something was wrong after the surgery began and realized they had operated on the wrong patient,” Chong said.
A preliminary investigation conducted by the hospital showed that the standard procedures required the nurse in the operation room to call the nurse in the ward before the patient was brought into the operation room. However, the physician failed to follow the procedures and personally called the nurse in the ward, which led to a series of errors afterward.
The Taiwan Joint Commission of Hospital Accreditation is to investigate the operation at the hospital following the major medical error, Deputy Minister of Health and Welfare Victor Wang (王必勝) said.
Specialists from the commission would need one month to conclude the investigation as they need to interview people involved in the incident, and review patients’ situations, the ministry said.
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