Clamp and surgical gauze left inside two surgery patients at Hong Kong Sanatorium and Hospital
Department of Health wants explanation for why it was not promptly notified about incidents as required by code of practice
A Hong Kong private hospital has been asked to explain why it failed to promptly notify the city’s health authorities about two incidents in which medical instruments and material were left inside patients after their procedures.
In the first case, a microvascular clamp was found inside a 63-year-old patient who had undergone an operation to remove part of his lower jaw at the Hong Kong Sanatorium and Hospital in Happy Valley on October 14 last year. The clamp was 1mm in diameter, a hospital spokeswoman said.
The error was discovered by hospital staff while they were doing an equipment count the same day, the Department of Health disclosed on Monday.
The department said the case was not reported by the hospital as required by the Code of Practice for Private Hospitals, Nursing Homes and Maternity Homes, but was detected by the authorities during a regular inspection on May 4.
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In another event on May 5, gauze was left in a 36-year-old patient during surgery to repair her perineum after a vaginal delivery. Medical staff remained unaware of this until the material was found in blood clots passed out the following day.
The hospital reported this event on May 8, despite the code of practice requiring it to do so within 24 hours.
The health department asked the hospital to submit a report on the incidents within four weeks. It issued an advisory letter to the hospital for its failure to comply with the reporting requirement and said it would monitor the risk mitigation measures put in place.
Medical errors must be taken seriously
A hospital spokeswoman said on Monday that it regretted the incidents and expressed its sincere sympathy for the patients.
She said the clamp in the first case had been removed from the patient, whose health was not affected. The instrument counting procedure had been reviewed.
For the second case, the spokeswoman said, the doctor-in-charge had explained the situation and prescribed antibiotics to the patient, whose health was not affected. She was discharged as scheduled.
The hospital had updated the guidelines in the delivery suite and improvement measures had been implemented after the event, the spokeswoman said.
Surgical gauze left inside Hong Kong man, 60, for 10 months
In January last year, the hospital also received an advisory letter for failing to report two incidents involving material left inside two patients in February and August 2016.
In October 2016, an advisory letter was sent to the hospital after a piece of surgical gauze was left in a 60-year-old patient’s abdomen during a laparotomy and colostomy the previous year. It was not detected until 10 months later.
An investigation showed that staff in the operating room had not strictly adhered to the hospital’s surgical count procedures for gauze pieces, breaching the requirements in the code of practice.
