On 8/18/2011, a gynecologist performed a Cesarean section and delivered a healthy baby to a patient.  The patient was a 21-year-old female who had failed to progress to delivery after labor had been medically induced.

Prior to closure of the patient’s abdomen to conclude the Cesarean section, the gynecologist and the surgical team recorded correct sponge, needle, and instrument counts.

In December 2011, the patient made multiple visits to the emergency department due to unresolved nausea and vomiting.  A CT scan on 12/21/2011 revealed a partial small bowel obstruction with a foreign body.  On 12/23/2011, a surgeon performed a laparotomy with adhesiolysis, drainage of an intra-abdominal abscess, repair of the patient’s small intestine, and retrieval of a laparotomy sponge.

Immediately after learning of the unintended retained sponge, the gynecologist contacted the patient and apologized personally and on behalf of the surgical team.  The gynecologist has made two changes to her surgical practice, intended to minimize the risk of recurrence of this error.  First, in addition to following the existing sponge count protocol, the gynecologist has surgical team members record any use of a sponge or towel in the abdomen on a whiteboard visible to the surgical team.  Second, the gynecologist now uses a special Cesarean section retractor designed to increase visibility and decrease the need for surgical sponges.

For this allegation and another, the Commission stipulated that the gynecologist reimburse costs to the Commission, develop a written protocol designed to prevent unintended retention of foreign body objects, write and submit a paper of at least 1000 words, with bibliography, in which she provides root cause analysis of the factors leading to the retained surgical sponge, write and submit a paper of at least 1000 words, with bibliography, containing a discussion regarding the need for visualization of the lining of the peritoneum and the correct performance of an appropriate laparoscopic approach for patients with a history of abdominal surgery, and present these two surgical cases to a peer group at a facility where she performs surgery.

State: Washington

Date: May 2015

Specialty: Gynecology

Symptom: Nausea Or Vomiting

Diagnosis: Post-operative/Operative Complication

Medical Error: Retained foreign body after surgery

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF