Tampon used to treat wound left inside Hong Kong patient by medical staff, report finds
Hospital Authority said 13 medical blunders were recorded in the second quarter of the year
A piece of tampon was found inside a woman after childbirth in a series of 13 medical blunders reported by Hong Kong public hospitals in the past few months.
The incident, reported in the quarterly magazine Risk Alert by the Hospital Authority, was among 13 sentinel events recorded in the second quarter of this year.
Of them, nine cases saw a various types of medical instruments being left inside patients’ bodies, including gauze, a clip, the trip of a drill bit, wire loop and others.
In one case, a women retrieved a piece of cotton wool from her vagina a few days after giving birth, which was later found to be a piece of tampon.
The report released on Friday said it was a result of “improper handling of a tampon” for repairing a wound. A vaginal scan and examination that followed showed no further abnormalities.
“The tampon is usually used when the doctor repairs the perineal tear wound to push up the uterus and stop the bleeding,” private obstetrician and gynaecologist Dr Kun Ka-yan said.
“If the tampon was found inside the patient, that means the medics have missed out at least two steps during the operation.”
Kun said the medic should have conducted an examination inside the vagina of the patient, and there should have been staff counting the total number of tampons being used during the process to ensure all were accounted for after surgery.
The report, without revealing any names or hospitals involved in the reported incidents, said the female patient was discharged by the public hospital two days after giving birth to her baby.
The report pointed out that the medics involved failed to comply with the standard practice to count all surgery items before closing the wounds in an operation.
They also failed to comply with the departmental guidelines on the repairing of a wound, and there was an improper use of a tampon.
While the report did not indicate whether any staff involved would be penalised, it said there is a need to reinforce the practice of counting items against the swab count sheet, and strengthen training on correct ways to use tampons for repairing tear wounds.
There was also one case of maternal morbidity and one case of incompatible blood group transfusion, both of which have been disclosed by the hospitals in the past few months before the publication.
‘The publication has been distributed to all health care professionals in public hospitals for continuous quality improvement purposes,” said a spokesman for the authority on Friday.