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Announcement on a Warfarin Incident

The spokesperson for the Prince of Wales Hospital today (September 7) made the following announcement regarding a sentinel event:

An 84-year-old female patient with chronic rheumatoid heart disease, hypertension, diabetes and history of stroke attended the medical outpatient clinic of the hospital on August 10. The attending doctor reviewed the patient’s blood coagulation index and adjusted the dosage of the anticoagulant Warfarin that she had been taking.

The patient attended the Accident and Emergency Department on August 28 due to impaired verbal ability and symptoms of stroke. She was then admitted to the hospital for further investigation. Computerized tomography scan results showed that she suffered from stroke with brain infarct and ischaemia.

The patient’s electronic medical records were checked and it was found that she was only prescribed half of the dosage of Warfarin that the doctor had intended on her attendance in the medical outpatient clinic.

The patient developed fever and urinary tract infection during her subsequent stay in the hospital and antibiotics were prescribed. On September 5, the patient’s condition further deteriorated. She suffered from septic shock, acute renal failure and cardiac arrest. Resuscitation failed and the patient passed away at around 6am.

The hospital had explained the incident and extended deep condolences to the deceased’s family. The hospital will continue to keep close contact with the family members and offer them necessary assistance.

The hospital had reported the incident to the Hospital Authority through the Advanced Incidents Reporting System. At this stage, the hospital has not yet been able to establish the cause of the prescribed dosage of Warfarin being less than the doctor’s intended dosage. The hospital will set up an investigation panel to look into the case in detail. A report is expected to be completed in about eight weeks.

As the cause of death is unknown, the case was reported to the Coroner.