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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 12/13/2017 12:00:00 AM
Country: South Korea
This alert addresses the patient safety incidents of retention of a foreign body following surgery. The alert provides two relevant cases involving retention of gauze, contributing factors and recommendations to prevent recurrence of similar incident. Included as well are requirements for counting during a surgical procedure and action guidelines for counting if a mismatch is discovered.

Additional Details

Device:
gauze, hemostatic gauze, productized sterile gauze

Rules / Policies / Procedures
  1. Number of gauze shall be counted separately by two people (one must be a visiting nurse) making a counting sound.
  2. Counting shall be done in the same order according to the regulations, in order according to the direction of progress (e.g., from large to small or from close to distant).
  3. First gauze counting shall be conducted and recorded to establish the standard for the coefficient and compare it at the next coefficient.
  4. The original shape of the gauze shall be used without cutting.
  5. Productized sterile gauze shall be also counted and incorrect gauze bundles shall be removed from the surgical field, bagged, labeled and separated.
  6. If gauze is added to the surgical field, count immediately and record it.
  7. Do not remove linen and trash containers from the room until the count is completed.
  8. Counted gauze shall not be used for postoperative wound packing.
  9. If used for wound packing, the number and shape of the packing gauze shall be recorded and handed over to the moving department. When the patient re-enter the operating room to remove the gauze, record the number and shape of the gauze.
  10. Accurately record the results of the counting and observe the behavioral guidelines when the counting is inconsistent.
  11. Used gauze shall be treated in leak-proof and tear-resistant containers in accordance with the hospital waste management regulations.

Patient safety incident caused by foreign substances remaining in the body after surgery (gauze)