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EGH Reportable Adverse Events (2009)

The following single (1) adverse event was reported to the Indiana State Department of Health. To put these events in context, there were 13,024 patients discharged from Elkhart General Hospital in 2009 with an average length of stay of 4.34 days. In 2009, EGH recorded 180,993 outpatient visits.

1. Foreign object left in a patient after surgery (March, 2009)

An anterior discectomy and cervical fusion at C 3-4 was performed on a patient and the case proceeded without incident. During the case two temporary fixation pins were inserted to hold the plate in position during the placement of the screws. The standard policy and practice for such a case is to view the area with a microscope through the fusion portion of the case so any pins retained could be viewed. It was not known at the time that there was one pin left in which was out of the physicians’ field of vision through the microscope. It was later learned that the temporary pin was angled in a way so it could not be viewed with a microscope. Full disclosure was made to the patient and the family. The patient was taken back into surgery to remove the temporary pin. The patient experienced no adverse outcome.

ACTION: A complete review of the case was conducted with the surgical team regarding the process for pin removal and counts. It was determined that all appropriate processes were followed according to policy. It was recommended to revise the count policy to note that anything temporarily placed in the wound that is to be removed before the wound is closed must be verbally noted, and noted on the count board and, must be verified for removal.