The Health and Disability Commissioner has recommended that a Health Board review its policies and processes after a surgical swab was left inside a patient during a procedure.

The patient went to the hospital for a routine surgery. Nothing unusual happened during the surgery. At each stage of the operation, the nurses confirmed that all surgical objects were accounted for. The patient was discharged from hospital after the operation to recover.

A few days later the patient went to her GP feeling unwell, and complaining of a lump. The GP urgently referred the patient back to hospital where she had a scan and further surgery to remove a swab.

The Commissioner held that although there was no clear explanation of how the incident occurred when all surgical objects were allegedly accounted for, everyone involved was responsible. The Health Board breached the patient’s right to have services provided with reasonable care and skill.

The Commissioner recommended that the Health Board require all surgical staff read the Count Policy, consider the orientation process for new staff, consider implementing periodic revision of its policy, and provide results of an audit.

It is important that all medical practitioners are familiar with hospital policies, and that those policies are effectively implemented by Health Boards to ensure the best health outcomes for their patients. Failure to do so may result in serious incidents risking the wellbeing of patients.

If there are concerns that a medical practitioner or hospital has failed to follow the appropriate process or policy, it is wise to speak with a professional experienced in the area.

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