The Hospital Authority today (29th) released the latest quarterly issue of "Risk Alert", which involved six incidents in which tools or medical materials were left behind in patients after surgical or interventional procedures.
A bedridden patient had to be fed by a nasogastric tube for a long time, and the nurse had to perform oral and nasal suction from time to time. Later, it was found that there was some residual material from the catheter in his diaper.
Two other patients were found to have pieces of dressing gauze left in the wound after the operation; another two patients had opaque shadows at the joints after the operation of the disc bone joint by X-ray detection. Metal shards suspected to be from surgical instruments.
The Hospital Authority today (29th) released the latest issue of the "Risk Bulletin" quarterly.
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This issue of the "Risk Alert" reports nine medical risk incidents, namely six incidents of instruments or medical materials left behind in patients after surgery or interventional procedures, two inpatient suicide cases and one maternal death in childbirth.
There were also 28 reported major risk events, including five cases of misidentification of patients or information, and the rest were all drug incidents.
Intermittent agitation and struggle of bedridden patients cause the hose to remain in the body
One of the cases involved a bedridden patient who was being fed by a nasogastric tube, and nurses and physiotherapists were required to perform oral and nasal suction from time to time due to the potential risk.
During a diaper examination, the patient's stool was found to have a 7cm long brown plastic tube.
After investigation, the plastic tube is likely to be part of the suction catheter (Suction catheter).
The report pointed out that due to the intermittent agitation and struggle of the patient, the catheter may be damaged during the suction process, and the medical staff should be more aware of the risk and should also be vigilant to check the integrity of the catheter after use.
Incorrect use of suction catheter as guide for tracheal surgery
Another patient underwent a temporary tracheotomy to create an artificial airway around March.
Later, it was found that the tracheostomy catheter fell off. When trying to reinsert the tracheostomy catheter, a suction catheter was used instead of a guide wire as an introducer to facilitate reinsertion.
After insertion, endoscopy revealed a tube in the patient's trachea extending down to the right main bronchus.
The suction catheter was removed under general anesthesia, and the patient was ultimately stable.
The publication states that a suction catheter is not recommended as the first choice for a tracheostomy tube.
The HA pointed out that the training of staff on correct tracheotomy and selection of suitable introducer should be strengthened, and the integrity of the suction catheter after use will be reviewed by two staff members.
The HA regularly publishes the "Risk Communication" report to remind medical staff to pay attention to medical malpractice.
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Wound dressing left over from excised breast
Regarding the two cases of gauze residue in the body, a post-mastectomy patient was found to have wound infection. After surgical exploration, daily wound dressings were required.
One week later, during the dressing period, a piece of plain gauze was removed from the wound.
The report pointed out that the area of ordinary gauze used for dressings is very small (5 cm x 5 cm), and the risk of accidental leftover in deep wounds is high, reminding doctors to use ordinary gauze or small dressing materials to treat some larger or deep wounds. Special care should be taken when cavitating wounds to prevent accidental retention.
A 5cm x 5cm piece of gauze was found left inside the mastectomy patient's wound.
The publication pointed out that special care should be taken when using small dressing materials to treat large wounds to avoid accidental leftovers.
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The gauze fragments remain in the nasal cavity for a month
Another patient underwent septoplasty and turbinate reduction surgery under general anesthesia. Due to continuous bleeding during the operation, the doctor inserted 2 pieces of iodoform paraffin gauze into the patient's nasal cavity.
On the first day of surgery, two pieces of gauze were torn into pieces due to difficulty in removing the gauze.
After a follow-up visit a month later, a 3 cm piece of gauze was removed from the patient's left nasal cavity.
The report mentions that longitudinally trimmed paraffin gauze can easily damage the gauze structure and increase the risk of removal, and it is recommended to develop a reference guide for the use of paraffin gauze for nasal packing.
The report recommends that a reference guide for the use of imitation paraffin plaster gauze (BIPP) for nasal packing should be developed.
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No need to remove radiopaque debris in the patient
The final case is about radiopaque debris in the patient's body.
A patient with a fracture of the A plate bone underwent hemi-hip replacement surgery, that is, replacing the hip joint with an artificial implant, but three months later, X-rays detected a 1 mm opaque shadow in the femoral canal.
After investigation, it was assumed that the operation was a femoral canal rasp used as a seam, with an irregular defect of 1 to 2 mm on the surface.
Patient B used the same set of instruments for surgery and also found a shadow of less than 1 mm in the disc bone canal.
The report said that despite a thorough and comprehensive investigation, the origin of the radiopaque debris could not be determined, possibly metal fragments from the instrument.
Given the good condition of the two patients, the hospital did not perform additional surgery to remove the debris.
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