Life-threatening anesthesia
Anesthesia is meant to relieve patients' pain, but it was not expected to be the main culprit in the series of accidents that led to the patients' deaths.
September 3, September 18, September 24, October 10, the second hospital in Sanming City, three consecutive patients in surgery and a patient after surgery, respiratory and cardiac arrest phenomenon, the patient could not be rescued accidental death.
According to the hospital, the four medical accidental deaths are: September 3, 26-year-old male patient Feng Guangle was admitted to the hospital, diagnosed with acute appendicitis. September 3 under continuous epidural anesthesia for appendectomy, surgery, respiratory and cardiac arrest, after 23 days of ineffective resuscitation at 00:44 hours on September 26, died.
September 18, 44-year-old female patient Zhang Chunmei uterine fibroid surgery, postoperative respiratory arrest in the ward, followed by cardiac arrest. She died at 18:32 on Sept. 26 after eight days of ineffective resuscitation.
On September 24, a 3-year-old boy, Zou Zhengtao, underwent surgery for a left inguinal hernia, and during anesthesia and surgery, the patient suffered sudden respiratory and cardiac arrest and pulmonary edema. Resuscitation after 7 hours ineffective in the afternoon of the day of surgery died.
According to the hospital, after the occurrence of the first three accidental deaths, Sanming City, health, drug supervision departments quickly organized experts to carry out investigation and analysis work, and invited Fujian Provincial Hospital, Provincial Union Hospital, Nanjing Military Region Fuzhou General Hospital of anesthesia experts, composed of the incident investigation expert team to the second hospital in Sanming City, the cause of the first three incidents to carry out investigations. However, just during the investigation, another patient death occurred.
On Oct. 10, a 29-year-old male patient, Jiang Chenfeng, underwent cranial repair under preparatory general anesthesia, and a few minutes after anesthesia-induced tracheal intubation, suffered a cardiac arrest, and died at 4:45 a.m. on Oct. 11 after 19 hours of ineffective resuscitation.
On October 14, the Fujian Provincial Department of Health expert group through a comprehensive analysis, that four cases are anesthesia accidents, anesthesia, anesthesia way, method, drug dosage and so on are standardized, rescue measures are reasonable, the cause of death is difficult to explain, no violation of medical practice.
October 15, the local government quickly carried out rectification work, removed the director of the anesthesiology department of this hospital, the incident involved anesthesiologists suspended clinical business activities, and the city's medical institutions anesthesiology department to organize inspections and remediation.
Preliminary conclusion - hospital mismanagement
October 16, the Ministry of Health and the provincial expert group preliminary investigation and analysis that the four anesthesia incidents and the second hospital in Sanming City, perioperative patient management is improper.
The preliminary investigation and analysis of the Ministry of Health and the provincial expert group that there are five main aspects of this hospital: First, hospital administrators and some medical staff do not pay enough attention to medical safety, anesthesiology part of the medical staff is not strong sense of responsibility, the awareness of medical safety is relatively indifferent to the level of medical technology is not high; the second is the implementation of the rules and regulations are not strictly implemented, did not strictly implement the norms of medical technology and routines, departmental Quality management is not in place, and there are hidden safety problems; third, the access to medical technology is not strictly controlled, and there are no clear requirements and regulations on the qualification of personnel to carry out difficult medical technology; fourth, the medical risk prevention, control and traceability mechanism has not been well established, and insufficient attention has been paid to the major problem of consecutive occurrence of patients' deaths during the perioperative period, and there has been no serious analysis and adoption of effective measures to intervene in a timely manner; fifth, the Sanming City Health Bureau, as the higher authority, did not well fulfill the administrative supervision and management responsibilities, and did not report to the higher health administrative departments in a timely manner as required.
The Fujian Provincial Department of Health has put forward five points to deal with this incident: notify the province of the four anesthesia incidents that occurred in the Second Hospital of Sanming City, and require health administrative departments and medical institutions at all levels to learn from their experiences, effectively strengthen the supervision and management of medical quality and medical safety, and timely detection of hidden problems in medical quality and safety, in order to prevent the occurrence of similar incidents; and instruct the Sanming City Health Bureau to Suspend the medical activities of the Department of Anesthesiology of the Second Hospital of Sanming City, immediately rectify the rectification, rectification by the Provincial Anesthesia Quality Control Center inspection and assessment before resuming medical activities, and do a good job during the rectification of the corresponding medical work.
At the same time, the Fujian Provincial Department of Health also recommended that the Sanming City, the second hospital of the relevant responsible persons to make administrative treatment, if any violation of the laws and regulations related to the management of medical institutions in accordance with the law. The government of Sanming City, Sanming City Health Bureau of the relevant leaders and the relevant responsible persons to make administrative treatment.
Just at the beginning of October, the Ministry of Health said it would establish a medical safety responsibility system and accountability system in health administrations across the country, and seriously investigate and deal with medical institutions that violate laws and regulations, neglect management, and have serious adverse medical incidents with bad social impact.
The deceased's family was awarded 400,000 yuan, the patient's cause of death is still difficult to determine
Until the afternoon of October 16, four cases, although it can be identified as anesthesia accidents, but the specific cause of death is still not clear.
Chen Baixi, deputy secretary of the party committee of the Second Hospital of Sanming City, said on October 16 that the phenomenon of surgical anesthesia accidents had occurred in the hospital in the past, but the patients could be rescued in time, and there had never been a case of death as a result. "If there is a problem with the hospital's management, why was it safe in the past and why has there been a spate of accidents lately?" He was also confused about this.
So are the anesthesiologists not good enough? Chen Baixi said the four surgeries that led to the anesthesia accident were carried out by three different anesthesiologists, the longest of whom had more than 20 years of service and the shortest had four or five years, and had not been involved in similar accidents before.
So is there a problem with the anesthetic drugs? According to the hospital's vice president, anesthesia expert Wei Xiuwu, four dead people used anesthesia drugs are not the same. Among them, the deceased Feng Guangle use of anesthetic drugs is lidocaine, the deceased Zhang Chunmei use of anesthetic drugs is bupivacaine and chloroprocaine, while the deceased Zou Zhengtao use of anesthetic drugs only bupivacaine a, the last deceased Jiang Chenfeng use of anesthetic drugs and the first three are different, is the midazolam, propofol, kamagra and fentanyl. Wei believes that if the four patients used in the anesthetic drugs have the same kind of anesthetic, then the drugs can be suspected, but the four patients used anesthetic and different, so it is difficult to judge is the anesthetic problem led to the four patients bizarre death.
But, according to Chen Baixi, after the anesthesia accident at the Second Hospital of Sanming City was disclosed by the media, they received a phone call from Jiangyan City in Jiangsu Province, saying that there had been a number of anesthesia accidents in that city as well, but just not as intensively as at the Second Hospital of Sanming City. According to another source, a similar phenomenon has also occurred in Fujian Putian City.
What exactly caused the spate of anesthesia accidents at the Second Hospital of Sanming City remains a mystery. The father of the deceased Feng Guangle, 57-year-old farmer Feng Kuangxu, despite getting 400,000 yuan in compensation and hardship allowance from the hospital, he still demanded a clear statement from the health department. "A child can't be resurrected after death, but you can't let a child die in such an unexplained way. The hospital should find out the cause as soon as possible and not let the tragedy repeat itself like this!" He cried.
Sanming City Second Hospital was founded in 1937, is a medical, teaching, scientific research, prevention as one of the "third class B" comprehensive hospital, responsible for Yongan City and the surrounding population of more than 2 million people of medical treatment tasks, is the national Ministry of Health recognized the international emergency rescue center network hospitals, is a medical insurance It is a network hospital of the International Emergency Rescue Center recognized by the Ministry of Health of the People's Republic of China, and a designated hospital for medical insurance. It has been awarded the national "Top 100 Hospitals" and "National People's Relief Hospital".