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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 a surgical procedure. A patient sustained an ankle fracture and underwent an open reduction and internal fixation operation using implants, including two parallel K-wires, a figure-of-eight wire over cortical screw and a washer; all were documented in the operation record. The implants were to be removed a year later. At that time, the doctor reviewed the patient’s pre-operative lower limb X-rays before the operation; these were displayed in the theatre and were referred to during the operation. The need for intra-operative X-ray screening was discussed but deemed not necessary. Post-operative X-ray was performed, and a retained 3.5mm washer was identified. Another operation was performed to remove the washer. Contributing factors and recommendations to prevent similar incidents are provided in the alert.

Additional Details

Device:
parallel K-wires, figure-of-eight wire overcortical screw, washer

Rules / Policies / Procedures
  1. Mandate the practice of intra-operative X-ray screening for all removal of implants operations.
  2. Reinforce thorough pre-operative planning for removal of implant operations, including review of previous operation record and pre-operative X-rays.

Retained Instruments / Material -- Metallic Washer