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UNSPLASH
About a month after surgery, a CT scan showed a mass in a woman’s left abdomen, consistent with a retained surgical swab. (File photo)
One woman was “traumatized” after a swab was mistakenly left inside her abdomen for about a month after surgery in Auckland.
In a recent ruling, the Health and Disability Commissioner (HDC) found that the Auckland DHB violated the Health and Disability Services Consumers’ Rights Code.
Former Commissioner Anthony Hill said the surgery “caused unnecessary damage and a lengthy recovery process.”
The woman, in her 40s, “is still suffering with the result,” she said.
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The woman had symptomatic arterial disease and pain caused by blocked arteries in her right thigh.
Alden Williams / Stuff
The woman filed a complaint with the Health and Disability Commissioner about the services provided to her by the Auckland DHB. (File photo)
He underwent surgery to increase blood flow to his legs.
However, three weeks after the surgery, the woman noticed a lump on the left side of her abdomen and, as a result, felt pain and “discomfort,” the commissioner heard.
She complained to her GP, who felt a soft, tender mass on her abdomen.
She was referred to the hospital, where a CT scan showed a mass on her abdomen, consistent with a surgical swab.
The woman underwent surgery the next day to remove the swab. Later she complained to the commissioner.
A clinical case review by the DHB was unable to explain how the swab was left inside the woman’s abdomen, as the swabs were counted after surgery and none were recorded as lost.
The review said that prior to the woman’s surgery, it had been identified that the wording of the counting policy needed to be revised.
It should have said that any item placed in any wound had to be reported and documented on the tally board, including insertion and removal times, depending on the review.
Routine practice at the time of vascular service was not to communicate or document when swabs were inserted and removed from the surgical site.
Prior to 2019, surgeons, anesthetists, and anesthesia technicians were not required to read DHB’s counting policy.
A registered nurse told the commissioner that all consumables and instruments were fully accounted for in the first final count.
Supplied
Former Health and Disability Commissioner Anthony Hill said the surgery “caused unnecessary damage and a lengthy recovery process.” (File photo)
Another registered nurse said there was no question or hesitation that the count was not correct.
Hill found that DHB failed to serve the woman with reasonable care and skill.
He said it was “very critical” the swab error had occurred and felt it was the responsibility of all staff involved in the surgery and the DHB.
He asked for more clarity on the counting policy and discrepancies in staff training.
“In my opinion, improvement in these areas can help reduce any unnecessary risk and opportunities for future swab errors,” Hill said.
Following the incident, the DHB updated its counting policy. A new audit of policy compliance is now also required to be completed annually.
“These are positive courses of action to help ensure any noncompliance is fixed,” Hill said.
