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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 10/1/2014 12:00:00 AM
Country: Hong Kong
This alert describes a patient safety incident of retention of a foreign body following a diagnostic procedure. A patient had medical termination of pregnancy in October 2013 and had repeated hospital admissions for abdominal pain. In January 2014, ultrasound guided drainage of the pelvic area produced aspiration of 20 mL of clear fluid. Insertion of a Pigtail catheter was subsequently attempted but failed. A CT scan of the abdomen in May 2014 revealed a linear 3 cm hyper dense shadow in the pelvic region, compatible with the tip of guide wire used during the procedure in January 2014. The patient was followed-up by the hospital for further management. Contributing factors to this incident included the following: 1. Role delineation of staff for surgical safety check was not clear. 2. The record on the instrument used was not ready for checking at the end of procedure. Recommendations to prevent similar patient safety incidents are provided.

Additional Details

Device:
Pig tail catheter, guide wire

Communication
  1. Conduct briefing session to staff on role of checking for surgical safety with focus on instrument integrity.
Rules / Policies / Procedures
  1. Assign designated staff to check instrument integrity.
Training
  1. Include surgical safety in staff orientation.

Retained Foreign Body in Peritoneal Cavity