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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 10/1/2021 12:00:00 AM
Country: Hong Kong

This alert describes retention of a foreign body following an invasive procedure. A nursing home resident was admitted esophago-gastroduodenoscopy (OGD) was performed to investigate the cause of anemia. The patient previously had frequent admissions, was on a gastric tube feeding and had episodes of agitation and struggling. The OGD procedure revealed a 5 cm long “broken catheter” in the duodenum, likely the distal end of a suction catheter used in the hospital. Agitated or struggling patients may have increased risk of biting the catheter during OP suction. Recommendations to prevent similar incidents are provided.

Additional Details

nasogastric tube, suction catheter

Retained Instruments / Material -- Broken catheter in patient’s duodenum