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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 4/1/2020 12:00:00 AM
Country: Hong Kong
This alert describes retention of a foreign body related to wound care. A metastatic breast cancer patient had a sacral wound, and wound packing was performed by an outreach team. After two admissions to two different hospitals, the outreach team continued to provide wound care for about 2 months, adopting the one-in-one-out principle for packing, and left a visible tail of packing out of the wound at all times. The packing materials were cut and stored in a sterile bottle at the patient’s home for packing use. The family members were told not to perform wound dressing themselves. When the patient was hospitalised for pneumonia, neither the wound packing nor any visible tail was noted during simple wound dressing. The next day, during wound nurse assessment, an extra piece of retained wound packing material was noted, on top of the wound packing provided by the outreach team. Contributing factors for this incident and recommendations to prevent similar incidents are provided.


Communication
  1. Remind carers not to perform wound packing themselves.
Rules / Policies / Procedures
  1. Explore improvement measures with wound nurses on the management of difficult wounds handled by outreach teams.

Retained Instruments / Material -- Dressing Material