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Prince of Wales Hospital announces retained gauze incidents

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Prince of Wales Hospital today (August 7) announced that the following retained gauze incidents occurred in recent months.

     In late July, the hospital received reports from two discharged obstetric patients that they had experienced abnormal lochia after giving birth on June 1 and 7. They attended the Maternity and Child Health Centre and a Mainland hospital. It was found that each woman had a piece of gauze retained in her vagina. The retained gauze was removed.

     According to hospital records, the episiotomy repair for the two women was performed by the same intern on the days of delivery. The hospital immediately conducted a look-back exercise to contact the other 26 whose episiotomy repair was performed by the same intern. In the meantime, the hospital has received a report from another woman, who gave birth on June 2, that a piece of gauze had been found in her vagina and that it had been taken out in a private hospital. Her episiotomy repair was also done by the same intern.

     The hospital immediately arranged follow-up appointments for these women and found that their wound condition was normal. Vaginal swabs were taken and antibiotics prescribed. The women did not require hospitalisation.

     For the other 25 women mentioned above, no similar situation has been found.

     The hospital yesterday (August 6) received another similar report from a woman who had delivered in the hospital on July 23. Her episiotomy repair was performed by a resident doctor. The gauze had been removed by a private doctor.

     The hospital is very concerned about the incidents. It is believed that the incidents may have been related to non-compliance with the guidelines on episiotomy repair. The hospital has immediately strengthened the guidelines, which now require the doctor to count the number of pieces of gauze together with a nurse after the procedure, in order to ensure that no gauze is retained in the patient's body.

     The hospital has offered apologies to the women concerned. To ensure patients' safety, the hospital has set up an enquiry hotline at 2632 3988 for women who have had vaginal delivery in the hospital in the past three months (May to July) and who may have experienced an abnormal situation, especially abnormal vaginal discharge. If necessary, examination at the Department of Obstetrics and Gynaecology will be arranged as soon as possible.

     The hospital has notified the Hospital Authority Head Office via the Advanced Incident Reporting System. An investigation panel will be set up to look into the root cause of the incidents and make improvement recommendations. The panel will submit its report to the Cluster Chief Executive in eight weeks. The composition of the panel is as follows:

- Dr Li Chi-kong, Chief of Service (Paediatrics)/Coordinator (Clinical Services), Prince of Wales Hospital

- Professor Peter Mok, member, Subcommittee on Quality and Safety, Hospital Governing Committee, Prince of Wales Hospital
- Dr Adrian Tse, Patient Safety and Risk Management Department, Hospital Authority Head Office
- Dr Chow Kam-ming, Chief of Service (Obstetrics and Gynaecology), Princess Margaret Hospital/Caritas Medical Centre/Yan Chai Hospital
- Ms Lai Chit-ying, Ward Manager (Obstetrics and Gynaecology), Princess Margaret Hospital
- Dr Cheung Lai-ping, Consultant (Obstetrics and Gynaecology), Prince of Wales Hospital
- Ms Karen Tse, Department Operations Manager (Operating Theatre), Prince of Wales Hospital     

Ends/Tuesday, August 7, 2012
Issued at HKT 19:58


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