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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 7/1/2020 12:00:00 AM
Country: Hong Kong
This alert describes a patient safety incident of retention of a foreign body related to wound care, documentation and continuity of care. A patient had been receiving sacral sore care by the Community Nursing Service (CNS) since December 2017. The patient’s wound outlet was getting smaller with deep tunnels and increased amount of exudate. Hydrofera blue foam was used for packing and was changed daily with a 3 cm tail fixed on the buttock skin. In January 2020, the patient was admitted due to worsening wound condition. The wound packing information could not be retrieved upon admission. The foam was not noted or removed during sacral wound dressing. Patient was discharged home and wound care by CNS resumed. In March 2020, the patient was readmitted as there was no improvement. During wound irrigation, a piece of 7 cm Hydrofera blue foam was flushed out from wound and was compatible with the one packed in January 2020.

Additional Details

Device:
Hydrofera blue foam

Communication
  1. Explore means to facilitate timely documentation of wound packing information.
Rules / Policies / Procedures
  1. Establish an effective communication system on wound documentation and its related management with the next carer.

Retained Instruments / Material -- Dressing Material