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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

Device:
ribbon gauze

Communication
  1. Reinforce nurses to report if there is discrepancy in the dressing material count.
Rules / Policies / Procedures
  1. Promulgate good practice of leaving distal end of the dressing material outside the wound for easy visualization and retrieval.
  2. Reinforce correct documentation of gauze count (actual number of gauze removed and packed) and essential information of packed items (material, number and length) on wound packing record.

Retained Instruments / Material -- Ribbon gauze