The Ministry of Health (MOH) released its review findings into the case of a patient who allegedly suffered a miscarriage after waiting for two hours at the National University Hospital (NUH) on Mar 15, 2022.
The woman claimed she experienced a miscarriage after waiting two hours at NUH’s Emergency Department (ED) and was not attended to.
Following the incident, MOH started an investigation carried out by a team of NUH senior doctors and nurses from the ED, Obstetrics & Gynaecology Department, and the Clinical Governance-Medical Affairs team.
MOH is satisfied that NUH has identified the gaps in processes and communication that had contributed to the incident and implemented the recommended corrective actions, said MOH in a press release on Wednesday (Apr 27).
However, MOH noted that while NUH’s overall assessment is that the processes and communications did not contribute to the miscarriage, there were gaps that needed to be improved.
Specifically, NUH had instituted a rapid access protocol for pregnant patients with signs of labour, after triage at the ED, to be transferred directly to the delivery suite for medical assessment instead of going through an ED doctor before the transfer.
MOH noted that the woman’s case involved an “unusually high number of patients at the ED”, and the delivery suite was full.
“The process of immediate transfer to the delivery suite had broken down, resulting in the patient not being seen in a timely manner.”
MOH added that NUH had held several meetings with the patient and her husband to clarify the facts of the incident.
“The couple has since accepted NUH’s clarifications and acknowledged that the miscarriage may not have occurred at the hospital,” said MOH.
Learning from this incident and addressing the identified gaps, NUH has implemented the following measures to strengthen care in the following areas and to prevent similar incidents from happening again:
- Patients who are pending transfer to the delivery suite will be triaged by the ED nurse and reviewed by the ED doctor who will communicate with the O&G doctor as clinically indicated;
- Based on clinical assessment, if indicated, pregnant patients may be evaluated using ultrasound at the ED;
- A standardised obstetric assessment score will be used in the ED to triage pregnant patients; and
- Following review by the O&G doctor, foetal heart monitoring will be done at the ED while waiting for a bed in the delivery suite.
- MOH has shared NUH’s investigation findings with the senior management of all public hospitals.
In addition, MOH has also reinforced to the public hospitals the clinical standards for the management of obstetric emergencies. /TISG