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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 1/1/2021 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety event of retention of a foreign body. A patient underwent right ureteroscopy and laser lithotripsy for right upper ureteric stone using a Stone Cone retrieval coil device to prevent ureteric stone fragments migration during laser lithotripsy. Resistance was encountered resistance while withdrawing the device and so the device was straightened to assist with removal. The device was finally withdrawn together with the ureteroscope. No significant residual stone fragment was detected. It was found that the end of the retrieved Stone Cone was blackened (burnt-like) with unsmooth surface during the final count. It was surmised that the device might be damaged by the scattering of the laser beam. Post-operative image revealed the retention of a Stone Cone fragment at the RIGHT distal ureter. The retained fragment (~6cm) was retrieved completely by another operation. The alert provides contributing factors and recommendations to prevent similar incidents.

Additional Details

Device:
Stone Cone retrieval coil, ureterscope, double-J catheter,


Retained Instruments / Material -- Broken Tip of stone retrieval device