The state’s Department of Public Health fined Hoag Memorial Hospital Presbyterian $25,000 for “failing to ensure patient safety” when a retractor blade was left in a patient’s abdomen and later removed during a second surgery, according to a report issued by the department.
During a surgery on April 14 to treat a patient with a renal mass, horseshoe kidney, lung cancer, thyroid cancer and pelvic mass, doctors and the nursing staff failed to complete an instrument count before the patient’s assistive breathing tube was removed and before doctors closed the patient’s skin over his stomach area, where the surgery was being performed, according to the report. Both items were violations of hospital policy, according to the report.
During the instrument count, the nursing staff learned a Bookwalter retractor blade was missing, according to the report. Doctors determined the blade was within the stomach area after an X-ray. Another surgery was performed to remove the blade, according to the report. The state department determined the violation “has caused, or is likely to cause, serious injury or death to the patient.”