On September 30, the Department of Health (HEALTH) received notification from Women & Infants Hospital of two separate cases of a patient with a retained foreign object (RFO) after surgery.
The first incident occurred on July 24 when a piece of rolled gauze was left inside a patient following a procedure to stop bleeding following a vaginal delivery. The second incident occurred on August 25 when a piece of marker thread from a surgical gauze separated and was left inside a patient’s abdomen following a gynecological procedure.
HEALTH conducted an investigation and determined that during the July incident, the obstetrical team did not follow the hospital’s policy about communication of patient information when the staff changed shifts resulting in the gauze roll being left in the patient’s vagina. During the August incident, HEALTH determined that the hospital’s surgical count policy was not followed. At the conclusion of the procedure, a surgical staff member noticed that the marker thread had separated from a gauze pad used during surgery. A piece of x-ray sensitive thread was found and removed before the patient left the operating room, but an x-ray was not done to confirm that the entire piece of thread was removed. (To view HEALTH’s statement of deficiencies of the incidents, visit http://www.health.ri.gov/discipline/hospitals/WomenAndInfantsFindings201011.pdf To view the federal statement of deficiencies, visit http://www.health.ri.gov/discipline/hospitals/WomenAndInfantsFederalFindings201011.pdf )
Seven physicians, one nurse, and one nurse anesthetist are being referred to their licensing boards for review.
“Although Women & Infants does not have a history of non-compliance with federal or state regulations or staff not following hospital policies, it concerns us that these incidents occurred,” said Director of Health David R. Gifford, MD, MPH. “This is a reminder that all hospital policies and procedures to prevent medical errors must be followed all the time. If surgical staff is unable to confirm that all instruments and items have been removed from a patient, an x-ray needs to be done before the patient leaves the operating room.”
Women & Infants must submit a plan of correction to HEALTH by December 2, 2010.