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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 1/1/2015 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 CT scan of the thorax, abdomen and pelvis. A tampon was inserted into the vagina for locating the pelvic position and documented on the CT examination report. The patient noticed a string coming out from the vagina 3 days later. The tampon was removed uneventfully. The key contributing factor was that there was inadequate documentation and counting of consumables used in radiological procedures. Recommendations to prevent similar patient safety incidents are provided.

Additional Details

Device:
tampon

Rules / Policies / Procedures
  1. Redesign the counting form to facilitate counting of consumables.
Training
  1. Identify indications for tampon insertion to alert relevant staff.

Tampon not Removed after CT Pelvis