Sponge left inside woman after surgery
Authorities have heard thousands of other complaints about care this year
Health authorities received nearly 9,000 complaints from patients over the quality of care in hospitals and other publicly funded health facilities in the past year, including one from a woman whose surgeon left a sponge inside her.
She suffered through serious post-operative bleeding and infections because of the object used to absorb blood, and it was missed on imaging scans.
The annual report by the independent patient care quality review boards shows the critical incident at St. Paul’s Hospital was followed by mistake after mistake. The surgeon intentionally left the sponge in the wound, intending for it to be removed at the first dressing change; a nurse mistakenly thought the sponge was mesh and “not a problem,” leaving it in the wound; health professionals did not provide “active and empathetic listening” to the patient’s concerns about pain and other symptoms; there was poor followup care and discharge planning; and only a verbal apology, not a written one, was provided after the errors. Quality review boards operate in each health region and deal with complaints that are not resolved through patient care quality offices at the local hospital or health region level.
In the errant sponge case, the review board recommended to Vancouver Coastal Health (a partner with Providence Health, which manages St. Paul’s Hospital) that it use surgical sponges with either a bar code or barium-saturated threads so they can be seen on radiology images when there is a concern they have been left inside the body.
The recommendations have been brought to the attention of the ministry of health, according to Dr. Jack Chritchley, chair of the Vancouver Coastal Health review board. Sophisticated new sponges that are easier to detect may be better since conventional sponges become “invisible” when they are full of blood, he said.
The patient required subsequent care for her complications and finding the original cause of her sepsis was a challenge.
As well, X-ray images done after surgery didn’t reveal the sponge — it was reportedly removed later by a general surgeon in the patient’s home community after he suspected there was a foreign object inside his patient.
The annual report says 7,107 of the nearly 9,000 complaints were about treatment or care of patients while the balance were about access to care, hospital discharge planning, communication and the attitudes or conduct of health professionals.
Chritchley said once again this year, patients or their advocates complained about inattention to mental health patients in hospital emergency departments. He said some mental health patients have left hospital without being seen by doctors, only to commit suicide shortly after.
Hospitals should have some way of following up with all patients who have registered with the nurse at the front triage desk to ensure that those who leave before being seen are safe. Some experts think there should be a separate door or triage desk for mental health patients, he said.
In one Fraser Health case, a patient who was a known suicide risk left hospital before a full assessment was completed and then died. The health authority has committed to developing a plan for communication with patients who leave prematurely.
Chritchley, who is also the chair of the Provincial Health Services review board, said another recurring problem is that vulnerable patients being released from hospital too often don’t have an easy-to-understand, comprehensive care plan showing what followup action is required.
“A lot of people don’t understand the written or verbal instructions they are given, if they are indeed given,” he said. “It may be that there are language barriers or problems with health literacy. That is why hospitals need to provide translators, and patients may need friends or relatives on hand when they are discharged.”
Apart from the missed sponge case, the review boards made recommendations in dozens of other incidents, including one for emergency health services paramedics to get more training for the assessment of babies and children experiencing allergic reactions and life-threatening anaphylaxis. That advice stemmed from a case in which paramedics on call in a remote community either didn’t use or didn’t have the proper dose of epinephrine to inject into a baby. Although the child survived, the emergency response was also complicated by travel to a hospital by ferry and a breakdown in communications with those who could provide medical advice by telephone.
To see the report, visit patientcarequalityreviewboard.ca. To request a review of a complaint already filed, call 1-866952-2448.