A woman complaining of chronic pain discovered she had a dinner plate-sized surgical tool inside her abdomen more than a year after giving birth to her baby by C-section, health officials said.
An extra-large Alexis retractor, or AWR, a device used to remove the edges of a wound during surgery that can measure 6 inches in diameter, was left inside a mother’s body after the birth of her baby at New York City Hospital. Auckland in 2020, according to a report by New Zealand’s health and disability commissioner.
“It should be noted that the retractor, a soft round tubal instrument made of clear plastic fixed in two rings, is a large item, approximately the size of a dinner plate,” the newly published report reads. “It is usually removed after the uterine incision is closed.”
The patient suffered in agonizing pain for 18 months, until the AWR was discovered on an abdominal CT scan and was finally removed in 2021, after multiple checkups that failed to identify the problem.
Te Whatu Ora Te Toka Tumai Auckland, formerly known as the Auckland District Health Board, previously denied failing to exercise reasonable skill and care towards the patient, pointing to “known error rates”.
However, on Monday, Health and Disability Commissioner Morag McDowell found the board in breach of the patients’ code of rights.
An extra-large Alexis retractor, or AWR, a device used to remove the edges of a wound, was left inside a woman’s abdomen for 18 months after she underwent a caesarean section. Applied Medical Resources
“There are substantial precedents to infer that when a foreign object is left inside a patient during an operation, care has been substandard,” McDowell wrote in his report. “It’s a ‘never’ event.”
The patient had a scheduled caesarean section at Auckland City Hospital due to concerns about placenta previa, a condition in which the placenta fully or partially covers the opening of the uterus.
During delivery, the count of all surgical instruments did not include the AWR, possibly “because the Alexis retractor does not go all the way into the wound, as the retractor half needs to stay outside the patient and therefore not run.” the risk of being retained,” a nurse said in the report.
One of the nurses present during the operation told the commission that she remembered opening a second AWR, which she said was “very unusual” and something she and her colleagues had never had to do before or since.
“I remember that the instrumentalist asked me to open another wound retractor for Alexis… [W]We didn’t have any in the prep room, so I quickly went to get one from the sterile supplies warehouse,” the nurse said. “I opened this to the instrumentalist and left it like that.”
The nurse added that she did not include the second AWR with the tool count, “as this item was not part of our count routine at this time.”
Over the next 18 months, the new mum sought medical help for her abdominal pain several times, including once at the Auckland City Hospital emergency department.
After the surgical tool was discovered in a CT scan and removed from the patient’s body, hospital staff involved in the C-section were said to be “really concerned” and “very apologetic”.
In the end, McDowell ruled that the board of health violated the patient’s rights.
The incident took place in 2020 at Auckland City Hospital in Auckland, New Zealand. PA
“As set forth in my report, the care was significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” the commissioner wrote. “There should have been systems in place to prevent this from happening.”
In his report, McDowell recommended that the board of health issue a written apology to the patient and, in the future, include the AWR as part of the surgical account.
Dr Mike Shepherd, Te Whatu Ora Health New Zealand Group COO of Te Toka Tumai Auckland, apologized for the error.
“On behalf of our Women’s Health service at Te Toka Tumai Auckland and Te Whatu Ora, I would like to express how sorry we are about what happened to the patient and acknowledge the impact this will have had on her and her whānau. [family group]Shepherd said in a statement.
“We want to assure the public that incidents like these are extremely rare and we remain confident in the quality of our surgical and maternity care,” he emphasized.
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Source: vtt.edu.vn