Case study: Surgical swab left in patient

background a female cat underwent an ovariohysterectomy, and as part of the procedure, was anaesthetised and intubated once she had recovered from the anaesthetic, she was discharged during a follow up visit, the vet who performed the procedure felt an abdominal mass when examining the cat, and asked the client to consider letting them perform an ultrasound during their next appointment if the mass was still there the client did not return to the clinic several years later, a veterinarian from a different clinic was examining the cat for another issue and felt the mass they performed a laparotomy to investigate and found a surgical swab had been left in the cat and was causing the mass the veterinarian noted that the cat did not appear to be in pain and was in good health the complaint the client made a complaint to vcnz about the veterinarian who performed the ovariohysterectomy and left the gauze swab inside their cat’s abdomen the issues raised in the complaint were whether the quality of care was appropriate and provided to the expected standard for veterinarians in new zealand how it was dealt with the complaints assessment committee (cac), which oversees the formal complaints process, considered it’s options under the veterinarians act 2005 (“the act”) and concluded that no further action was required it found that there was no evidence of previous or subsequent similar incidents involving the veterinarian, and did not find that the veterinarian acted in a way that would call for discipline under section 50 of the veterinarians act 2005 the cac acknowledged that the veterinarian took full responsibility for the error by sending a written apology to the client, and putting a protocol in place to do a swab and needle count at the beginning and end of each surgery learnings for the profession the case provides an example of a veterinarian taking responsibility for their mistake and being proactive in managing the situation with a client the veterinarian demonstrated to the cac that they had mitigated the chances of a similar issue from happening again the cac noted that while the situation had caused the client some distress, it was an isolated event and did not raise concerns about the veterinarians competence in its finding, the cac highlighted the importance for all clinical staff members to be aware of, and understand, standard operating procedures for more information about vcnz’s complaints process, visit https //www vetcouncil org nz/web/1 support and information/vets/concerns aspx https //www vetcouncil org nz/web/1 support and information/vets/concerns aspx