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The Prince of Wales Hospital Releases Investigation Findings on Retained Gauze Incidents

The Prince of Wales Hospital today (11 October) released the findings of the Investigation Panel regarding four incidents of retained gauzes.

An intern of the Department of Obstetrics and Gynaecology performed episiotomy repair for three women who delivered on 1, 2 and 7 June, 2012 respectively. The patients experienced abnormal lochia after discharge and attended the Maternity and Child Health Centre, a private hospital and a Mainland hospital respectively. A piece of gauze was found to have retained in their vagina and it was removed. The fourth incident happened on 23 July, 2012. A discharged woman was found to have a piece of gauze retained in her vagina and her episiotomy repair was performed by a resident doctor. The hospital took an immediate decision to set up an investigation panel to investigate the four incidents. Conditions of the four patients are now normal and they require no further follow-up.

The Panel has identified the root causes of the incidents involving the intern as follows:
1. Adjusting the safe practice in handling gauzes: At the beginning of the training, the intern did follow the safe practice when using gauzes for haemostasis by leaving the end of the gauze outside the body during wound repair. But he later considered that putting the whole gauze into the vagina could prevent the flow of blood from blocking his view and he could perform the procedure better. He then adjusted his practice without notifying the supervisor.

2. Missing the counting of gauzes after the procedure: The department required the operator to personally count the number of gauzes after the episiotomy repair and sign off the counting form. However, the intern did not clearly understand the purpose of the form and misinterpreted that the signing was to indicate who the operator of the procedure was.
3. Focusing the post-wound repair vaginal examination on wound gaps only: While performing vaginal examination after the episiotomy repair, the intern only focused on signs of gapping and had not explored the likely retention of foreign objects.

4. The gauze counting system was prone to human error: When gauzes were taken out from the pack, the quantity was not immediately documented. The wordings on the form were ambiguous and may be misinterpreted.

For the investigation report involving the resident, the Panel noted that during delivery the fetus sustained fetal bradycardia and the resident had decided to use vacuum extraction to help the delivery. The baby was born with low birth weight and a bluish mark on its body. The case resident had been distracted by the baby’s condition and missed leaving the end of the gauze outside the body when repairing the episiotomy wound in accordance with the safe practice in handling gauzes. And she had not counted the number of gauzes correctly when signing off the counting form and paid attention to any retained gauze when examining the wound.

The Panel made the following recommendations regarding the four incidents:
1. Strengthen the training and supervision of doctors
- Establish a structured assessment on episiotomy repair. Interns have to pass the assessment before they can perform the procedure independently.
- Encourage staff to alert the interns’ supervisors when they detect any deviation from normal practice.
- Reinforce safety awareness regarding surgeries and clinical procedures, including the importance of counting and risk of item retention.

2. Improve the counting system
- Double counting of the gauzes by the operator of the episiotomy repair with another staff.
- Document the quantity of gauzes on the form immediately after unpacking.
- Enhance the design of the gauze counting form and use clearer wordings.

3. Remind staff to be vigilant when performing post-wound repair vaginal examination to exclude the possibility of the retention of foreign objects.

The hospital has accepted the investigation results and the Panel’s recommendations. A series of improvement measures has already been implemented and the report has been submitted to the Hospital Authority Head Office. Follow-up actions will be taken according to established human resources procedures. The hospital wishes to express her sincere apology to the affected patients once again.