四大失誤　調錯嬰兒 伊院補鑊推連串措施

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【本報訊】伊利沙伯醫院的醫護人員連環犯下四項錯誤，觸發「調錯嬰」事件。院方昨日透露，涉事三名醫護人員沒有即時為嬰兒戴上腳帶，佩戴腳帶及放上BB床時又沒有核對資料，其後護士交更五次也沒正確核對嬰兒資料。院方昨推出一系列改善措施「補鑊」，但有病人組織直指職員尊重病人意識不足才是禍根，擔心同類事件不斷重演。
記者：白琳　梁洵瑜
伊院婦產科部門主管黃漢光昨表示，本月 7日 25號床及 10號床女嬰分別於凌晨 1時許及2時許出生，當時醫護人員即時為她們戴上寫有母親資料的手帶，並先後轉送往產後病房。醫護人員沒按既定程序即時為其列印及戴上腳帶，反而待兩名女嬰到齊，才一併為兩人列印腳帶，犯下第一宗罪。當日至清晨 6時，只有三名嬰兒在伊院出生。
證實前五天　一直餵母乳醫護人員約凌晨 5時再連犯兩錯。他們把兩女嬰放到 BB床上時沒有核對床號；套上腳帶時也沒有核對資料，導致兩人的床位及腳帶對調。
伊院規定，護士每天早上 6時半、下午 1時及晚上 9時交更時，必須核對手帶腳帶的資料，該病房事發 33小時內共交更五次，護士也沒發現出錯，犯下第四宗罪。直至 10號女嬰的母親本月 8日下午 1時發現「女兒」的手帶資料不符，才揭發事件。
院方其後向雙方父母解釋並安排 DNA測試，其間五天雙方母親繼續為對方的女嬰餵哺母乳，直至本月 12日，即女嬰出生第六天，DNA測試才證實兩人身份對調。黃漢光強調，就算上述母親沒揭發事件，嬰兒出院時護士會重新核對手帶、腳帶及母親資料，確實嬰兒身份，因此過往及將來也不會發生「養錯嬰」事件。
伊院昨提出多項改善措施，包括把手帶改為腳帶，以及醫護人員核對資料後須簽名核實等，並成立調查委員會，四周內提交報告。伊院行政總監熊志添向兩名女嬰的父母致歉，「佢哋好唔開心，好大困擾。」但沒有回應他們是否接受院方解釋。院方已向涉及事件最少三名員工作出訓示，但會否進行懲罰，則留待調查委員會完成報告。
據了解，醫院管理局事發後沒向食物及衞生局通報。食衞局局長周一嶽昨午稱非常關注事件，又批評類似事件「絕不該發生」，要求醫管局立即徹查並呈交報告，如有疏忽或錯誤，應盡快向公眾交代。
調查委員會成員之一、醫管局總護理行政經理馮玉娟表示，會調查有否環境因素分散員工注意力導致出錯等，但強調即使工作量多，也不是出錯的藉口。
態度不改善　恐重蹈覆轍社區組織協會病人權益組織幹事彭鴻昌批評，事件反映公立醫院前線人員沒有尊重病人的意識，上述父母或因此承受永久心靈傷害，建議局方設工作坊提升職員意識，「如果職員態度唔改善，指引寫得幾好都冇用，以後都會有呢啲事發生。」
伊利沙伯醫院調錯嬰改善措施•以左腳帶代替左手帶，以防嬰兒收水後手帶脫落
•戴上左腳帶之後，職員必須在母親面前為嬰兒佩戴右腳帶並簽名核實
•涉事職員接受再培訓及監察
•提醒職員嚴格執行識別嬰兒身份的程序
•成立調查委員會

資料來源：伊利沙伯醫院

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