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Publication Type: Risk Alert
Single or Multiple Incident: Multiple
Date: 4/1/2021 12:00:00 AM
Country: Hong Kong

This alert describes two patient safety incidents of retention of a foreign body. In both cases an endobag was retained. In the first case a second endobag was inadvertently deployed after repositioning the patient and the endobags were obscured from the operator’s view. A nurse handover contributed to the incident. In the second case repositioning of the patient, nurse handover and lack of including the endobag in a final count contributed to the incident. A recommendation to prevent similar incidents is provided.

Additional Details

Raytec gauze, endobag

Retained Instruments / Material -- Endobags