A Hong Kong patient has found gauze measuring up to 18.5cm (7.3 inches) in length in his scrotum, two months after an operation at a public hospital.
The discovery was among seven “sentinel events” in the third quarter last year, according to a quarterly newsletter published by the Hospital Authority on Monday.
The patient had undergone testicle removal surgery. One piece of ribbon gauze was packed into each scrotal wound, and the left testis was covered with paraffin gauze.
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A surgeon later replaced the pieces of ribbon gauze after the patient complained of groin pain. The paraffin gauze was kept in the left side of the scrotum but the surgeon noted on record that “all dressings were removed” and the two pieces of ribbon gauze were replaced.
A recovery room nurse verified with the surgeon and added to the nursing record that “one paraffin gauze still remained in the wound”.
Despite this, ward nurses only replaced the ribbon gauzes during daily dressing, with the paraffin one going unnoticed.
The patient later underwent two ultrasound scans at two public hospitals. Reports from the scans showed the presence of suspected surgical material in the left side of the scrotum.
But the urology teams at both hospitals decided against exploring the wound and only recommended to follow up as planned.
Two months after the operation, the patient noticed discharge from the scrotum and punctured the area himself, spotting white-coloured material in the wound.
Two pieces of fragmented paraffin gauze were later retrieved. The pieces measured 6cm by 7.5cm and 18.5cm by 7.5cm.
The authority advised healthcare professionals to avoid packing paraffin gauze into deep cavities, leave a 3cm tail of the packing materials at skin level and ensure the accuracy of records.
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