A woman complaining of chronic pain found she had a surgical instrument the size of a dinner plate in her stomach more than a year after giving birth to her baby by cesarean section, health officials said.
The larger Alexis retractor, or AWR – a tool used to retract the edges of a surgical wound that can be 6 inches in diameter – was left in a mother’s body after the birth of her baby at Auckland City Hospital in 2020, according to a report by the health and disability commissioner New Zealand.
“It should be noted that the retractor, a soft round tube instrument of transparent plastic attached to two rings, is a large item, about the size of a dinner plate,” the newly released report reads. “Usually, it will be removed after closing the uterine incision.”
The patient suffered excruciating pain for 18 months, until the AWR was discovered on an abdominal CT scan and finally removed in 2021 — after several tests that failed to identify the problem.
Te Whatu Ora Te Toka Tumai Auckland, formerly known as the Auckland District Health Board, previously denied that it had failed to exercise reasonable skill and care towards patients, pointing to a “known rate of error.”
On Monday, however, Health and Disability Commissioner Morag McDowell found the board breached the patient rights code.
The larger Alexis retractor, or AWR — a device used to retract the edges of the wound — was left in the woman’s abdomen for 18 months after she had a C-section. Applied Medicine Resources
“There is substantial precedent for concluding that when a foreign object is left inside a patient during an operation, care falls below an appropriate standard,” McDowell wrote in his report. “It was a ‘never’ event.”
The patient underwent a scheduled caesarean section at Auckland City Hospital because of concerns about placenta previa — a condition in which the placenta completely or partially covers the opening of the uterus.
During the delivery, the count of all surgical instruments did not include the AWR, possibly “due to the fact that the Alexis Retractor does not go completely into the wound because half of the retractor has to be outside the patient and therefore it will not be at risk of being retained,” said a nurse quoted in the report. that.
One of the nurses present during the operation told the commission that she remembered opening the second AWR, which she said was “very unusual” and something she and her colleagues had never had to do before or since.
“I remember being asked by the scrub nurse to open another wound retractor for Alexis… [W]I didn’t have anything in the preparation room, so I quickly took it from the sterile stock room,” said the nurse. “I opened this to the scrub nurse and left it at that.”
The nurse added that she did not include the second AWR with the instrument count, “because at this time this item is not part of our count routine.”
Over the next 18 months, the new mother sought medical attention for her abdominal pain several times, including once in the emergency department of Auckland City Hospital.
After the surgical instrument was found in a CT scan and removed from the patient’s body, the hospital staff involved in the C-section were said to be “really concerned” and “profoundly apologetic.”
Ultimately, McDowell ruled that the health board violated patients’ rights.
The incident occurred in 2020 at Auckland City Hospital in Auckland, New Zealand. AP
“As noted in my report, the care fell significantly below the appropriate standard in this case and resulted in a prolonged period of hardship for the woman,” the commissioner wrote. “Systems should be in place to prevent this from happening.”
In his report, McDowell recommended that the health board issue a written apology to the patient and, in turn, include the AWR as part of the surgery count.
Dr. Mike Shepherd, Te Whatu Ora Health New Zealand group operations director for Auckland’s Te Toka Tumai, apologized for the error.
“On behalf of our Women’s Health services at Te Toka Tumai Auckland and Te Whatu Ora, I would like to say how sorry we are for what happened to the patient, and acknowledge the impact it has had on her and her family. [family group],” Shepherd said in a statement.
“We want to assure the public that this kind of incident is extremely rare, and we remain confident in the quality of our surgical and maternity care,” he stressed.
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Source: thtrangdai.edu.vn/en/
