"Dinner-plate-sized" surgical instrument found inside New Zealand woman 18 months after cesarean section
Key Takeaways
A surgical tool was found inside the abdomen of a New Zealand woman 18 months after she underwent a cesarean section.
An investigation found that the surgery fell “below the standard of care.”
Systems are in place at hospitals around the nation—and the world—to help avoid serious surgical errors.
A large Alexis wound retractor reported to be the “size of a dinner plate” was found inside the abdomen of a New Zealand woman 18 months after she underwent a cesarean section, according to The Guardian. The woman, who has not been identified, is in her 20s. She had a scheduled cesarean section procedure at Auckland City Hospital in 2020, after which she experienced chronic pain for months. Her pain was so severe and persistent that it prompted several visits to her primary care doctor and one visit to the Auckland City Hospital’s emergency department.[]
In 2021, the woman underwent an unrelated CT scan. The scan revealed the Alexis wound retractor instrument, which was not detectable by x-ray. A second surgery was performed to remove the wound retractor, at which point the instrument had been inside the woman’s abdomen for approximately 18 months.[]
Te Whatu Ora Auckland, formerly Auckland District Health Board, claimed that it had not failed to exercise reasonable skill or care toward the patient. However, the New Zealand Health and Disability Commissioner, Morag McDowell, launched an investigation into the incident. In a full report on the case, McDowell strongly disagreed with Te Whatu Ora Auckland’s statement.[]
The report states that a complete medical team was present during the 2020 cesarean, including a surgeon, two anesthesiologists, four nurses, two anesthesiology technicians, a registrar, and a midwife. It further details that a count of all instruments used during the procedure did not include the Alexis surgical wound retractor. According to the report, one of the nurses involved in the cesarean told commission investigators that the instrument was likely left off the count because “‘the Alexis Retractor doesn’t go into the wound completely as half of the retractor needs to remain outside the patient, and so it would not be at risk of being retained.’”[]
In the report, the commissioner noted that this incident closely resembled a 2018 case at a hospital guided by Te Whatu Ora Aukland, in which a surgical swab was left in a patient’s abdomen. The commission has advised Te Whatu Ora Aukland to revise policies for surgical instrument counting and record-keeping to improve clarity and reduce the risk of future errors. Commissioner McDowell’s final report also states that it’s clear Auckland City Hospital fell below the standard of care when it failed to identify the instrument during routine surgical checks, resulting in it being left inside the patient’s abdomen.[][]
“There is substantial precedent to infer that when a foreign object is left inside a patient during an operation, the care fell below the appropriate standard. It is a ‘never’ event,” the report states.
As a result of the investigation and report, Te Whatu Ora Auckland has issued an apology and assured the public that this case has led to improvements in its policies and standards. Speaking on behalf of Te Whata Ora Auckland, Group Director of Operations, Mike Shepard, MD, stated, “I would like to say how sorry we are for what happened to the patient and acknowledge the impact that this will have had on her and her whānau [family group].. “[W]e have reviewed the patient’s care, and this has resulted in improvements to our systems and processes, which will reduce the chance of similar incidents happening again. We acknowledge the recommendations made in the commissioner’s report, which we have either implemented or are working towards implementing.”[]
The woman’s case is now being reviewed to see if any further action, including possible disciplinary action against Auckland City Hospital, will be taken.[]
Preventing surgical errors
Preventing surgical errors is a frequent and important topic for hospitals, medical groups, insurance companies, and healthcare organizations worldwide. In the alone, approximately 50 million surgeries are performed annually. A 2015 study suggests that as many as 1 in 100,000 surgeries performed in the US are performed at the wrong site. Wrong-site surgeries and other serious errors, such as instruments being left inside a patient, are sometimes referred to as “never events.” A never event is defined as a medical error that causes severe harm to a patient that is both easily identifiable and preventable.[]
David L. Feldman, MD, MBA, CPE, FAAPL, FACS, Senior Vice President and Chief Medical Officer of Healthcare Risk Advisors (a New York City–based group offering professional liability insurance to physicians) and Chief Medical Officer of The Doctors Company, says that surgical errors often fall into this category: “When you operate on somebody, and something goes wrong, it’s usually pretty obvious.” he says. “These events [include things] like wrong surgery [or] retained surgical items. These things people say should never happen—these surgical misadventures. We have a pretty reasonable idea of how to fix that. We haven’t fixed it all yet, but there are some good ideas out there.”
Ideas for reducing such “never events” have been suggested and implemented around the country and the world. For instance, the Joint Commission has created National Patient Safety Goals dedicated to eliminating wrong-site surgery, including preprocedural verification of the patient, procedure, surgical site, and the presence of all supplies. Similarly, the World Health Organization’s Safe Surgery Saves Lives campaign recommends a three-step sign-in, time-out, and sign-out process to reduce errors, including surgical items left in the body and wrong-site surgery. On a smaller scale, many hospitals nationwide use perioperative tracking and data-keeping based on US military communications and operations procedures.[]