National Taiwan University Hospital (NTUH) on Saturday said a nurse had accidentally used tap water instead of reverse osmosis purified water on dialysis patients in an intensive care unit, but that the death of one of the patients was not related to the incident.
The Taiwan Healthcare Reform Foundation yesterday said the hospital should have reported the case to the Ministry of Health and Welfare.
The ministry said it has asked the local health department to look into the case.
A local media outlet on Saturday afternoon reported that a nurse at NTUH’s intensive care unit had accidentally connected a tube meant for reverse osmosis purified water to tap water, and one of the six patients in the unit had died.
NTUH issued a statement later the same day saying that it had conducted a review immediately after the incident, and changed procedures and improved its equipment to prevent similar accidents.
It had explained the situation and apologized to patients and their families, the hospital said.
There is no evidence to suggest that the patient’s death, which happened a few days after the accident, was related, it said, adding that a preliminary review showed that the cause of death was associated with the patient’s illness.
The foundation yesterday said that, since a 2011 case involving NTUH where organs from a donor infected with HIV were accidentally transplanted into five recipients, it has advocated for regulations that require healthcare facilities to report serious medical malpractice to governing agencies within 24 hours, and that investigations be conducted by an independent ad hoc team.
“These cases show that healthcare facilities are often passive and only unwillingly respond after they are exposed by the media or patients complain,” foundation deputy chief executive Chu Hsien-kuang (朱顯光) said yesterday.
“The investigation was conducted by NTUH, which might not clear the public’s doubts, because [the hospital] has been both the player and the referee,” he said, adding that facilities and the government should review how they respond to serious malpractice cases, because the public is unsatisfied.
Department of Medical Affairs Director-General Shih Chung-liang (石崇良) said the department was not informed of the case, and he found out about it through the media.
“I have asked the Taipei Department of Health to follow regulations when investigating this case and have requested that NTUH submit a report in three days,” he said.
“If an investigation shows that a healthcare facility is to blame for a management error that results in a patient’s death, it could be fined between NT$100,000 and NT$500,000 according to Article 118 of the Medical Act (醫療法),” Shih said.
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