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Topic: Surgery
Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 10/1/2011 12:00:00 AM
Country: Hong Kong
Organization: Hong Kong Hospital Authority

This safety alert describes a patient safety incident where a patient experienced a post-operative infection due to a retained surgical gauze in her body. An emergency caesarean hysterectomy was performed on a patient with massive post-partum haemorrhage. Two scrub nurses assisted the operation while two circulating nurses counted off and weighed the bags of blood-soaked gauzes to estimate blood loss. The scrub nurse and a circulating nurse did the final surgical counting before wound closure (including counting the number of tied-up gauzes already put away in the bags). No discrepancy was detected. The mother and baby were discharged after 5 days. The mother was admitted via the emergency department for left loin pain 9 months later. Plain abdominal x-ray and CT scan revealed a retained gauze in the the patient. A long raytec gauze was removed in a subsequent elective laparoscopic operation. The patient’s recovery was uneventful after the operation. Factors that were considered to have contributed to the incident were: - Failure to conduct final count of individual number of raytec gauzes at the end of the operation. - Unclear role delineation among the nurses in surgical counting.

Raytec Gauze