A six-year wait: Hong Kong patient has broken medical device left inside him until he undergoes another spine operation
Doctors are urged to check whether devices are complete when they are removed from the body
The broken part of a medical device was left in a patient for six years and was only discovered when the patient underwent a second spine operation in a public hospital, a newsletter from the Hospital Authority revealed.
The 4cm part of the perforated wound drain was found inside the patient when further treatment for the patient’s spine degeneration problem was performed last year.
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The date and location of the surgery was not disclosed in the latest issue of Risk Alert, which covered the third quarter of last year.
The item came from one of three drains placed for a spinal stenosis operation performed on the patient in 2009.
Two drains were removed on the day of the surgery and the other was taken out three days later. The patient was discharged after another three days.
The newsletter did not identify a cause for the broken drain.It also noted that X-ray detection of such drains was difficult.
Several recommendations were made to prevent similar incidents, including checking whether drains are complete when they are removed from a body.
This case was one of five involving medical instruments or materials left inside patients’ bodies.
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Among “serious untoward events” recoded in the newsletter, a patient suffered second-degree facial burns from a surgical fire in an unnamed hospital. It was caused by a spark generated by a medical device being used near the patient’s nose.
A burn covering an area of 6cm by 4cm was reported.
The surgeon involved also had superficial burns on both palms.
The report concluded that the fire happened because the device was close to an oxygen-enriched environment.
A guideline to prevent fires during surgery was suggested to prevent similar incidents.
The Hospital Authority also published on Thursday its annual report on serious incidents in the 12 months from October 1, 2014 to September 30 last year.
It reported 39 “sentinel” events, as compared to 49 in the last reporting period.
It also reported a decline for the second year running in the number of “serious untoward events”. It said there were 68 in the reporting period, among which 57 were related to medication errors and 11 involved patient misidentification.
