The Hospital Authority today (30th) released the latest issue of the "Risk Bulletin" quarterly, which stated that public hospitals reported 7 medical risk warning events in the first quarter of this year, including when a doctor performed an operation on a cataract patient, even though he was already in his right eye. The mark was marked, but the error still meant that the left and right injections of anesthetic were injected. The doctor discovered the mistake after the injection was completed. The patient agreed to continue the operation after learning of the incident, and there were no sequelae.
In addition, a patient with perianal swelling was left with two pieces of hemostatic gauze in the wound after undergoing an incision drainage operation. When the nurse tried to remove the gauze for the patient after the operation, she did not find the gauze and she did not report the matter. , I only thought that the gauze had fallen by itself, and indicated that the gauze had been completely removed, and the victim revealed the incident at a follow-up consultation 4 days later.
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When a doctor performed an operation on a cataract patient, he mistakenly injected an anesthetic to the left eye during retrobulbar block.
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The right eyebrow has been marked. The doctor confirmed with the patient before the operation
The new issue of "Risk Bulletin" reports 7 medical warning events, including a doctor performing an operation on a cataract patient during retrobulbar block, although the doctor has marked the right eyebrow to be operated on. He confirmed with the patient the eye to be operated on, but the doctor soon injected anesthetics into the left eye, and the doctor later discovered that the injection was the wrong eye.
He immediately assessed the patient's condition and determined that the patient's condition was stable and there were no complications related to anesthesia, and the operation was continued with the patient's consent.
The authorities believe that the doctor involved did not carefully examine the eyes to be treated, and the lack of attention and distraction during the operation led to this incident. It is recommended that the doctor pause for a while before injecting the anesthetic, and reconfirm that the treatment is required. To prevent the incident from happening again.
The Hospital Authority released the latest issue of the "Risk Bulletin" quarterly today (30th).
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The nurse thought she dropped the gauze on her own to check the patient's wound
In addition, there are also 3 cases of leftover tools or medical materials in the patient’s body, including a patient with perianal abscess who underwent emergency incision and drainage after general anesthesia. Two pieces of hemostatic gauze (ribbon gauze) were used to bandage the wound.
The doctor removed one of the gauze for the victim the next morning, and then instructed the nurse to remove the remaining one. The nurse did not find that the patient’s gauze was missing, thinking that the gauze had fallen off by itself, and recorded on the document as “only for The patient bandaged a piece of gauze" (only one new ribbon gauze was packed), and the related gauze was also removed.
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The patient's follow-up consultation began after 4 days
The patient went to the general outpatient clinic for follow-up consultation 4 days later. The outpatient nurse found two pieces of gauze in his wound, one of which was consistent with the gauze used during the operation, which meant that the gauze stayed in the patient's wound for up to 5 days, and the wound healed well after treatment.
The authorities believe that it is generally difficult for the medical staff to detect the hemostatic gauze in the small wound, and the person involved is not familiar with the notification mechanism, and failed to promptly notify the patient of the number of gauze on the patient and the record is incorrect, and then even wrongly recorded "the gauze has been completely removed." (Complete removal of gauze).
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