A surgical swab which was accidentally left in a woman's abdomen during surgery at a public hospital led to "unnecessary harm" a report found today.
The Office of the Health and Disability Commissioner's report found Auckland District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) over the incident.
"The woman had symptomatic artery disease and claudication (pain caused by obstruction of the arteries) in her right thigh," the report reads.
"She underwent an elective aorto-right iliac bypass graft (placement of grafts on the aorta and the right iliac artery to bypass a blood vessel that is blocked or narrowed, to increase blood flow to the legs). This was performed by the hospital’s vascular service.
"The surgery was reportedly performed in accordance with the vascular service’s standard procedure. The nurses counted items used during the surgery as required, and no items were unaccounted for. The surgeons were notified of, and acknowledged, the correct count."
Despite this, the report states a swab was left in the woman’s abdomen, which was not discovered until almost four weeks later.
"The DHB conducted a clinical case review but was unable to explain how the swab was retained, given that the surgical count was recorded as correct."
Due to the error, former Commissioner Anthony Hill found that the DHB failed to provide services with reasonable care and skill, and was "highly critical that the error occurred".
"The DHB needed to ensure that its system provided [the woman] with safe care of an appropriate standard," said Hill.
"Somehow, that system failed [the woman], and a swab was left inside her abdomen… As a result of this, the surgery caused unnecessary harm and a protracted recovery process for [the woman]."
Hill recommended a number of changes to ensure it didn't happen again.
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