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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 1/1/2020 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident of retained foreign body left in a patient after an abdominal hysterectomy and bilateral salpingo-oopherectomy. A metal malleable retractor was placed in the abdomen to retract the abdominal organs to facilitate abdominal cavity closure. The first count was reported as ‘correct’ while the retractor was still in use. The second count was incomplete as not all instruments in used instruments tray could be checked by two nurses due to time constraint and distractions. Patient was transferred to Recovery Room after reversal and extubation. During final count, a malleable retractor could not be found and subsequent X-ray showed a retained retractor. The patient was sent back to the operating theatre to retrieve the retained retractor. Recommendations to prevent similar incidents are provided.

Additional Details

Device:
metal malleable retractor, sharps, needles, gauzes, hysterectomy trays


3947 - - Retained Instruments / Material -- Metal Retractor Left in Abdomen