Drill bits left in patients
DHBs have reported 63 surgical mishaps over the past three years, with women most frequently affected
Swabs, bandages and drill bits have been left in patients after recent surgeries — and women undergoing gynaecological procedures are particularly affected.
Health boards have reported 63 incidents over the past three years where materials or surgical items were mistakenly left in patients too long.
In one case, a surgical drill bit snapped and a piece was left in a patient’s jaw. It was removed after a more senior surgeon reviewed the case and thought it could cause damage.
Another person suffered repeat infections after a drainage tube was left in their chest for three years.
A Herald survey of adverse event reports for each of the country’s 20 DHBs shows about a third of cases happened when swabs, gauze and bandages were left inside women after childbirth or gynaecological procedures. That number may be higher, given many DHBs don’t specify what surgery was carried out when listing “retained foreign object” incidents.
Health boards have policies to prevent items being left after surgery, including making sure every item in theatre is checklisted before and after a surgery. However, in some cases policies weren’t in place, or weren’t followed. Staff under pressure and poor equipment design were also cited as factors.
At Counties Manukau, a vaginal pack was left in a patient and gauze was left in another woman after being taken from a trolley after the final equipment count was done.
Whanganui DHB filed a report in 2015-2016, after a woman who had a routine gynaecological surgery went to ED a few days later because of pain and other symptoms. Six weeks later she was back at ED, in even worse shape. A CT scan showed a surgical clip was blocking a duct connecting the kidney to the bladder.
“The patient required further multiple surgeries and . . . continues to have problems requiring treatment at another DHB,” the report states.
Sue Claridge, co-ordinator of the Auckland Women’s Health Council, said women often bore the brunt of medical mishap.
That was demonstrated by the use of surgical mesh, which was removed from supply for some gynaecological procedures in December 2017 after problems including infection and chronic pain.
The reported cases of retained objects were low, Claridge said, but could be the “tip of the iceberg”, given research had shown adverse events were generally under-reported.
Mistakes happened, she said. The response was crucial.
“How seriously are they taking patients when they complain something’s not right, and what systems and processes are being put in place to ensure it doesn’t happen again?”
Adverse events are monitored by the Health Quality and Safety Commission, which has circulated documents advising how to guard against mishaps.
It also supports simulation training, and promotes the use of a safety checklist, including a count of items such as instruments and sponges.
A spokeswoman for the commission said existing systems were effective in preventing mistakes.