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Topic: Surgery
Publication Type: Safety Learning Summary
Single or Multiple Incident: single
Date: 3/1/2009 12:00:00 AM
Country: Canada
Organization: Winnipeg Regional Health Authority (Canada)

"An elderly patient underwent complex abdominal surgery that was performed by three surgeons (one general and two specialty surgeons) and two separate nursing teams. The surgical instrument count performed at changeover was indicated as correct on the patient's medical record. It was unclear if the instruments used by the specialty surgeons were still in the operating theatre or if they had been removed from the room. A number of months later, the patient visited a physician with a complaint of hip pain. An x-ray revealed the presence of a surgical instrument in the patient's pelvis and it was removed during a second surgery. The patient was discharged home without complication."



Elderly patient with new hip pain found to have retained surgical instrument following complex abdominal surgery