Forgetting to remove instruments and medical supplies from inside a patient after surgery is becoming very rare thanks to new procedures, but in spite of checklists and other measures, still occurs

Forgetting to remove instruments and medical supplies from inside a patient after surgery is becoming very rare thanks to new procedures, but in spite of checklists and other measures, still occurs
Photo Credit: Pascal Lauener/Reuters

Shocking case of surgical forgetfulness

(original Radio-Canada/CBC report links at bottom)

Montrealer Sylvie Dubé was experiencing abdominal problems and swelling last year. When she finally went to her doctor, the verdict was ovarian cancer.

First came chemotherapy, but that was followed by a hysterectomy on March 14th of this year at Notre-Dame Hospital, part of the Centre Hospitalier de l’Université de Montréal. (CHUM).

Upon awakening following the surgery she said she felt like she was being stabbed.

X-ray shows the large metal tool 33 cm in length which was left inside MMe Dubé. It is used to hold organs in place during surgeries.
X-ray shows the large metal tool 33 cm in length which was left inside MMe Dubé. It is used to hold organs in place during surgeries. © Radio-Canada

The pain went from her abdomen to her shoulder, but staff told her it was normal to feel pain elsewhere following a hysterectomy.

More chemo treatment followed along with anti-inflammation medicine and cortisone injections in the shoulder, but the pain continued and got worse.

By May 22, the pain was so intense she went to the hospital emergency room where an x-ray showed a large metal tool that had been left inside her body from the earlier surgery..

On the 25th, another surgery removed the tool.

Mme Sylvie Dubé in an exclusive Radio-Canada interview describing her ordeal.
Mme Sylvie Dubé in an exclusive Radio-Canada interview describing her ordeal. © Radio-Canada

These days operations in surgical theatres have a check list and staff are supposed to count all tools and equipment out loud prior to an operation and once again before the patient leaves the theatre. If the counts don’t match, the patient is supposed to be immediately x-rayed.

Although such cases are now few and becoming fewer still, Quebec has a higher rate of such incidences than other provinces in Canada.

© CIHI / CBC

The CHUM says it is unsure what went wrong in this case, but is investigating. The incident has prompted changes in the CHUM network for all operations.

Sources

Categories: Health
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