Two Incidents of Retained Foreign Objects Reported at Women & Infants Hospital
Thursday, November 18, 2010
According to HEALTH, the first incident occurred on July 24 when a piece of gauze was left inside a patient following a procedure to stop bleeding following a vaginal delivery. The second incident occurred on August 25 when a piece of marker thread from a surgical gauze separated and was left inside a patient’s abdomen following a gynecological procedure. As a result, seven physicians, one nurse, and one nurse anesthetist are being referred to their licensing boards for review.
How It Happened
A HEALTH investigation found that the obstetrical team did not follow the hospital’s policy about communication of patient information when the staff changed shifts resulting in the gauze roll being left in the patient’s vagina in the July incident. During the August incident, HEALTH determined that the hospital’s surgical count policy was not followed–a standard practice that when overlooked or conducted inaccurately, has led to a retained foreign object (RFO) after surgery. At the conclusion of the August procedure, a surgical staff member noticed that the marker thread had separated from a gauze pad used during surgery. A piece of x-ray sensitive thread was found and removed before the patient left the operating room, but an x-ray was not done to confirm that the entire piece of thread was removed.
"Concerning" Trend
“Although Women & Infants does not have a history of non-compliance with federal or state regulations or staff not following hospital policies, it concerns us that these incidents occurred,” said Director of Health David R. Gifford, MD, MPH in a statement. “This is a reminder that all hospital policies and procedures to prevent medical errors must be followed all the time. If surgical staff is unable to confirm that all instruments and items have been removed from a patient, an x-ray needs to be done before the patient leaves the operating room.”
RFOs have earned the state much unwanted national attention, as GoLocalProv.com reported on October 27, 2010, when Rhode Island Hospital was hit Tuesday with a $300,000 fine when, during neurosurgery, a small piece of a drill bit broke off and was left lodged in a patient's scalp. The fine was, to date, the highest issued by HEALTH in state history. Women & Infants must submit a plan of correction to HEALTH by December 2, 2010.
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