The Department of Health directed the Provincial General Hospital to replace the RO water supply system for dialysis after the incident.

Leaders of Nghe An Department of Health inform about medical incident in artificial kidney dialysis. Photo: PV

Dialysis water is contaminated!

At the press conference on the afternoon of August 5 organized by the Nghe An Department of Health about the medical incident of artificial kidney dialysis at Nghe An General Hospital, a representative of the Hanoi Institute of Occupational Health and Environment - the unit that conducted the testing of RO water samples for dialysis at Nghe An General Hospital - said that of the 3 water samples tested, sample number 3 (taken at the end of the RO water pipe) had a high amount of bacteria. The conclusion was that the water was contaminated with bacteria exceeding the threshold.

Reporters asked questions to leaders of the Department of Health and the Provincial General Hospital. Photo: PV

Dr. Nguyen Huu Dung - Head of the Department of Artificial Kidney of Bach Mai Hospital added: RO water used for dialysis is ultra-pure water but not sterile water. When the RO water system has bends, plaque will form, allowing bacteria to survive and multiply here.

“The dialysis incident in Hoa Binh province two years ago was caused by chemicals, while here it was caused by water contaminated with bacteria,” Mr. Dung compared.

Quick test results of RO water system Photo: PV

At the press conference, many reporters attending the press conference asked the Hanoi Institute of Occupational Health and Environment, the Department of Health, and Nghe An General Hospital to provide the test results. A representative of Nghe An General Hospital said "they will provide them later".

According to the quick water sample test results of the Friendship General Hospital after the incident on August 1, the standard "Soft water hardness does not meet" was met.

Is there regular cleaning?

Dr. Nguyen Huu Dung informed at the press conference. Photo: PV

Also at the press conference, Dr. Nguyen Huu Dung said: Bach Mai Hospital is responsible for assisting, directing, and guiding the Provincial General Hospital, not being a partner or being hired or hired. Only when Nghe An General Hospital requests will Bach Mai Hospital send people in. Every year, Nghe An General Hospital requests 1-2 times.

Dr. Dung added: According to the regulations of the Ministry of Health, the inspection and cleaning of the artificial kidney dialysis system must be done once every 3 months. Particularly at Bach Mai Hospital, the inspection and cleaning are done once a month. During the latest support visit to Nghe An General Hospital on June 23, experts from Bach Mai Hospital also warned about the risk of this incident and suggested replacing the RO water pipe system (which is bent and has been used for 5 years). However, this hospital did not accept it.

Mr. Nguyen Van Huong - Director of Nghe An General Friendship Hospital admitted that he had received the above warning, but according to Mr. Huong, "the hospital had not had time to replace the pipeline when the incident occurred."
“After this incident, we will replace the entire pipeline system to ensure safety,” said Mr. Huong.

Dr. Nguyen Huu Dung said that according to the regulations of the Ministry of Health, the dialysis system needs to be maintained and cleaned once every 3 months. Photo: PV

Regarding this issue, at the press conference, reporters asked the General Hospital to provide records and the latest RO water test results, but the hospital has not responded.

Personal responsibility not clear

Associate Professor, Dr. Duong Dinh Chinh - Director of Nghe An Department of Health said that the dialysis system of Nghe An General Hospital will be allowed to operate again when it meets all safety criteria. Photo: PV

Associate Professor, Dr. Duong Dinh Chinh - Director of Nghe An Department of Health said that the responsibility for the incident lies with the Director of the General Hospital of Friendship. "Whether or not to take disciplinary action will be considered by the leaders of the Department of Health. If it is at the level that requires disciplinary action, the Department of Health will establish a Disciplinary Council, meet and submit to the Provincial People's Committee for decision. Regarding the responsibility of departments and individuals under the management of the Hospital, the Department of Health will assign the Director of the Hospital to consider," said Mr. Chinh.

At the press conference, reporters raised the question: In this incident, 10 patients had a bad turn. All 10 of these patients only had dialysis on 3/21 machines. This shows that after the first incidents, the on-duty team of the Department of Nephrology - Urology - Dialysis continued to give dialysis to patients on the machines that had the incident. At the same time, it also shows that on July 30, there must have been at least 3 patients receiving dialysis. Could the incident have been less severe if these 3 machines had been temporarily suspended? What is the responsibility of the doctors here?

In response to this question, the officials responsible for answering only listed 20 possible adverse reactions to people undergoing dialysis and did not go into the specific responsibilities of doctors and nurses for patient safety.

At the end of the press conference, a representative of the Nghe An Department of Health said: It will direct the Provincial General Hospital to replace the old RO water pipe system with a drinking pipe system. When the causes at the General Hospital are thoroughly resolved, and the test results are up to standard and stable, the Department of Health will allow the dialysis system here to operate again.

Regarding this incident, on August 2, the People's Committee of Nghe An province issued a document assigning the Nghe An Department of Health to direct the review of the entire hemodialysis process to accurately determine the cause of the above incident, thoroughly implement solutions, and ensure absolute safety before the hemodialysis system at the Provincial General Hospital resumes operation; strictly handle organizations and individuals if there are violations according to the law.