SURGICAL DRAIN

Description of Event or Problem

A (B)(6) YEAR OLD MALE WITH DEGENERATIVE JOINT DISEASE, UNDERWENT LEFT TOTAL KNEE REPLACEMENT. POST OP ORDERS WERE ENTERED FOR A SURGICAL DRAIN, INCLUDING TO REMOVE THE DRAIN THE NEXT DAY, AND THE PATIENT WAS DISCHARGED ON DAY 2. THREE DAYS LATER THE PATIENT PRESENTED TO THE EMERGENCY DEPARTMENT FOR BLEEDING FROM THE INCISION. WORK UP DID NOT IDENTIFY ANY ACUTE PROBLEMS AND THE PATIENT WAS DISCHARGED. AT AN ORTHO OFFICE VISIT, AN X-RAY IDENTIFIED A RETAINED FOREIGN BODY AND THE PATIENT RETURNED FOR SURGERY TO REMOVE A SEGMENT OF A SURGICAL DRAIN. THE PATIENT WAS DISCHARGED TO HOME LATER THAT DAY. EVENT INVESTIGATED BY CLINICAL MANAGERS AND REFERRED TO NURSING PEER REVIEW FROM PERSPECTIVE OF REMOVAL ON SURGICAL UNIT AS WELL AS INITIATING LINE/DRAIN/AIRWAY ENTRY INTO THE MEDICAL RECORD IN THE OPERATING ROOM. REFERRALS ALSO MADE TO SURGICAL PEER REVIEW FOR DOCUMENTATION CONCERNS AND TO ED AND RADIOLOGY PEER REVIEW FOR THE MISSED RETAINED FOREIGN BODY.