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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 9/1/2015 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident of retention of a foreign body following a procedure. A patient required long-term tube feeding. Feeding tubes were changed when necessary. At a later point, an abdominal X-ray was taken as a diagnostic related to the patient’s fever; it revealed a radio-opaque line in the right lower quadrant. A 36 cm segment of silicone feeding tube was removed via colonoscopy uneventfully. The contributing factor in this incident was that there was failure to check for the integrity / completeness of the instrument upon removal.

Additional Details

Device:
feeding tube


Retained segment of feeding tube