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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 7/1/2021 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident of retention of a foreign body following surgery. Two ribbon gauzes were packed into the wound, one removed the next day. Due to false reassurance that the remaining gauze was found and lack of documentation of discrepancy of gauze count, the second ribbon remained in the patient until four days later. Recommendations to prevent similar incidents are provided.

Additional Details

ribbon gauze

Retained Instruments / Material -- Ribbon gauze