Medical device used during labor falls out of patient 10 weeks later

As Laura Jokinen made her way home from a walk with her newborn son in October 2018, the shooting pain she’d been experiencing in her abdomen for weeks became unbearable.

She limped home and buckled to the floor, screaming for her husband to help.

“It was at that point I reached down and felt a metal device protruding out of my vagina,” said Jokinen, who works in health care as a risks assessment researcher.

“I freaked out … I didn’t know what the device was or where it came from. It looked almost like a battery, and there were wires that were running up inside me. I was afraid to remove it, because I wasn’t sure if it was attached to my insides.”

The experience points to alarming statistics. Canada saw a major jump — 14 per cent over the last five years — in the number of medical items left inside patients after procedures, according to a study released Thursday by the Canadian Institute for Health Information (CIHI), a not-for-profit group that collects data on the quality of health care in the country. 

CIHI said 553 such objects were left inside patients over the last two years. 

Canada has the highest rate among developed countries of medical items being left inside patients, according to a separate study from the Organization for Economic Co-operation and Development (OECD).

That means medical teams across the country need to do a better job of following existing safety procedures, according to Sandi Kossey, senior director of the Canadian Patient Safety Institute (CPSI), a not-for-profit healthcare watchdog.

“There are checks and balances that should happen,” said Kossey. “There are enough preventative measures that should be in place, that these things should not happen.”

Jokinen, who lives in Parksville, B.C., had to have an emergency caesarean section on Aug. 11, 2018, at the Nanaimo General Hospital.

Before surgery, the medical team attached an electrode to the baby’s head while he was still in the womb to monitor his heartbeat.

Part of the monitor was removed during the C-section. But the medical team forgot to take out the rest. 

Two weeks after Jokinen was discharged, she started having complications: an infection of her surgical incision and heavy, prolonged vaginal bleeding.

Her doctors prescribed antibiotics but didn’t detect what had been left inside her. It remained there for 10 weeks until it dislodged.

Jokinen tried to find out, through the regional health authority, what the monitor was made of and how the mistake might have affected her health and that of her baby.

“At that point, he was two months old and I was breastfeeding, so I was really concerned about what risks this posed to his health,” Jokinen said.

Jokinen says she was on pins and needles for more than a month waiting to hear back. The response she finally got, she says, was less than helpful.

The Vancouver Island Health Authority told her even the manufacturer couldn’t say what the effect might be since the device was only designed and tested for use over periods of 24 hours or less.

It said it looked at devices made of similar materials and didn’t believe there were any long-term risks to Jokinen or her baby from the breakdown of the components. 

Jokinen says she wanted the health authority to take responsibility, but it refused, saying the failure was by the surgeon who is an independent contractor and not an employee. 

“Physicians in B.C. are independent contractors who are licensed and regulated by the College of Physicians and Surgeons of B.C.,” the authority said in an email to Go Public. 

Jokinen said she was surprised by  the health authority’s reaction.

“They’re responsible for their subcontractor’s actions and … providing safeguards to make sure that people aren’t harmed.”

Kossey, at the CPSI, agrees. “Certainly, they are responsible for what happens under their watch and within their facility,” she said. 

Jokinen chose not to pursue action against the surgeon.

Go Public reached out to HealthCareCAN, an organization that represents hospitals across Canada, for comment but did not immediately hear back. 

‘Systemic flaw’

According to the most recent report on the quality of healthcare in OECD countries, a foreign body — sponges, needles, clamps, scissors, etc. — is left inside a patient in Canada 9.8 times out of every 100,000 surgeries. That’s three times the average.

The next-highest OECD results were Sweden at 8.3 followed by Netherlands with 4.6 per 100,000.

“The data shows that we’re not doing as good as we should be as a developed country,” Kossey told Go Public. 

But she also suggests the reason Canada appears to have more mistakes could be in the accuracy of the reporting itself.

“Some of the other countries … being compared against may have different cultures around how they’re collecting and using that information … it’s a bit of a mixed signal,” she said. 

Kossey says medical teams need to ensure they do an appropriate inventory of equipment used during all procedures and to communicate clearly with the patient and family members — even in the most chaotic situations — what’s being done so there are no surprises.

Jokinen was surprised to hear how often something goes wrong. “That points at a systemic flaw in our healthcare system,” she said.

“In order to address that, we need to first acknowledge that it’s happening. The health authorities need to take responsibility for the actions of their subcontractors and they also have to come up with a mitigation plan to avoid these types of events,” she said. 

The Vancouver Island Health Authority told Jokinen it has made changes. Non-surgical devices like the monitor that was left inside her were added to a checklist of items that need to be retrieved after medical procedures.

“We deeply regret that this patient had a poor care experience and we sincerely apologize to her,” a spokesperson wrote in its email to Go Public.

via: https://www.cbc.ca/news/health/fetal-monitor-left-inside-surgical-medical-error-1.5349111

Photo Credit: Laura Jokinen