Fatal anesthesia
The original intention of anesthesia is to alleviate the pain of patients, but unexpectedly it has become the chief culprit leading to the death of patients in this series of accidents.
On September 3rd, 8th, 24th and 6th 10, there were 3 consecutive cases of respiratory cardiac arrest in Sanming Second Hospital. 1 patient died unexpectedly after operation.
According to the hospital, the four cases of medical accidental death are as follows: On September 3, a 26-year-old male patient, Feng, was admitted to the hospital and was diagnosed as acute appendicitis. On September 3rd, appendectomy was performed under continuous epidural anesthesia. Respiratory cardiac arrest occurred during the operation. After 23 days of rescue, he died at 0: 44 on September 26.
On September 18, a 44-year-old female patient, Zhang Chunmei, underwent hysteromyoma surgery. After the operation, she stopped breathing in the ward and then her heart stopped beating. After 8 days of rescue, he died on September 26th 18: 32.
On September 24th, Zou, a 3-year-old boy, underwent left inguinal hernia surgery. During anesthesia and surgery, the patient suddenly developed breathing, cardiac arrest and pulmonary edema. Seven hours after the rescue, he died on the afternoon of the operation.
According to the hospital, after the first three accidental deaths, the health and drug supervision departments of Sanming City quickly organized experts to carry out investigation and analysis, and invited anesthesia experts from Fujian Provincial Hospital, Provincial Union Medical College Hospital and Fuzhou General Hospital of Nanjing Military Region to form an incident investigation expert group to go to Sanming Second Hospital to investigate the causes of the first three incidents. However, during the investigation, another patient died.
1June 10, a 29-year-old male patient, Jiang Chenfeng, received skull repair under general anesthesia. A few minutes after anesthesia induced tracheal intubation, he had a cardiac arrest. After being rescued 19 hours, he died at 4: 45 am on June1/kloc-0.
65438+1October 65438+April, the expert group of Fujian Provincial Health Department, through comprehensive analysis, concluded that all four cases were anesthesia accidents, the route, method and dosage of anesthetic drugs were standardized, the rescue measures were reasonable, the cause of death was difficult to explain at present, and there was no violation of medical operating procedures.
10On June 55438+05, the local government quickly carried out rectification work, replaced the director of anesthesiology department of the hospital, suspended the clinical business activities of anesthesiologists involved in the incident, and organized inspection and rectification of anesthesiology departments of medical institutions in the city.
Preliminary conclusion-improper hospital management
1June 16, the preliminary investigation and analysis by the Ministry of Health and the provincial expert group concluded that these four anesthesia incidents were related to improper perioperative patient management in Sanming Second Hospital.
According to the preliminary investigation and analysis of the Ministry of Health and the provincial expert group, there are five main problems in this hospital: first, hospital administrators and some medical staff pay insufficient attention to medical safety, some medical staff in anesthesiology department are not responsible enough, their awareness of medical safety is relatively indifferent, and their medical technical level is not high; Second, the rules and regulations are not implemented, the operating norms and routines of medical technology are not strictly implemented, the quality management of departments is not in place, and there are security risks; Third, the access to medical technology is not strict, and there are no clear requirements and regulations for the qualifications of personnel who carry out difficult medical technology; Fourth, the prevention, control and traceability mechanism of medical risks has not been established and perfected, and the major problems of continuous death during perioperative period have not been paid enough attention, analyzed seriously, and effective measures have not been taken to intervene in time; Fifth, Sanming Health Bureau, as the superior competent department, did not perform its administrative supervision and management duties well and did not report to the superior health administrative department in time as required.
The Health Department of Fujian Province put forward five suggestions to deal with this incident: inform the whole province of four anesthesia incidents in Sanming Second Hospital, and ask health administrative departments and medical institutions at all levels to draw inferences from others, learn from experience and lessons, strengthen the supervision and management of medical quality and medical safety, discover hidden dangers of medical quality and safety in time, and prevent similar incidents from happening; The Sanming Municipal Health Bureau was instructed to suspend the medical activities of the Anesthesiology Department of the Second Hospital of Sanming City and immediately rectify it. After the rectification, medical activities can be resumed only after the provincial anesthesia quality control center has passed the inspection and evaluation, and the corresponding medical work should be done well during the rectification.
At the same time, the Fujian Provincial Health Department also suggested that the relevant responsible persons of Sanming Second Hospital should be dealt with administratively, and those who violate the relevant laws and regulations on the management of medical institutions should be dealt with according to law. Sanming Municipal Government has given administrative treatment to the relevant leaders and responsible persons of Sanming Municipal Health Bureau.
Just at the beginning of 10, the Ministry of Health said that it would establish a medical safety responsibility system and accountability system in the national health administrative departments, and seriously investigate and deal with medical institutions that violate laws and regulations, neglect management, have serious medical adverse events and have a bad social impact.
The family of the deceased was compensated 400,000 yuan, and the cause of death of the patient is still difficult to determine.
By the afternoon of June 65438+1October 65438+June, although 4 cases can be identified as anesthesia accidents, the specific cause of death is still unknown.
Chen Baixi, deputy secretary of the Party Committee of Sanming Second Hospital, said in June 10 that there was an accident in surgical anesthesia, which happened in this hospital in the past, but all the patients were rescued in time and there were no deaths. "If there is a problem with hospital management, why are they all safe before, but there have been many accidents recently?" He is also at a loss about it.
So, is the level of anesthesiologists unqualified? Chen Baixi said that four operations that caused anesthesia accidents were performed by three different anesthesiologists. Among them, the length of service is more than 20 years, and the short period is four or five years. There have been no similar accidents before.
So, what's wrong with narcotics? According to Wei Xiuwu, vice president and anesthesiologist of the hospital, the narcotic drugs used by the four deceased were not the same. Among them, the anesthetic used by the deceased Feng was lidocaine, the anesthetic used by the deceased was bupivacaine and chloroprocaine, while the anesthetic used by the deceased Zou was bupivacaine only. The anesthetic used by the last deceased Jiang Chenfeng was different from the first three, namely midazolam, propofol, carnosine and fentanyl. Wei believes that if four patients use the same anesthetic, then the drug is doubtful, but the anesthetic used by the four patients is different, so it is difficult to judge that the anesthetic problem caused the bizarre death of the four patients.
However, according to Chen Baixi, after the anesthesia accident in Sanming Second Hospital was disclosed by the media, they received a phone call from Jiangyan City, Jiangsu Province, saying that there were too many anesthesia accidents in this city, but it was not as dense as Sanming Second Hospital. According to relevant sources, a similar phenomenon has appeared in Putian City, Fujian Province.
What caused the anesthesia accident in Sanming Second Hospital is still a mystery. Although Feng Kuangxu, the father of the deceased and a 57-year-old farmer, received 400,000 yuan in compensation and hardship subsidies from the hospital, he still asked the health department to give a clear statement. "Children can't be resurrected when they are dead, but they can't die like this. The hospital should find out the reason as soon as possible and can't let the tragedy repeat itself! " He cried and said.
Sanming Second Hospital, founded in 1937, is a "three-class-B" comprehensive hospital integrating medical treatment, teaching, scientific research and prevention. Responsible for the medical treatment of more than 2 million people in Yong' an and surrounding areas. It is an international emergency rescue center network hospital recognized by the Ministry of Health and a designated medical insurance hospital. Won the national "Top 100 Hospitals" and "National People's Trust Hospital"