Description of Event or Problem · 0
PATIENT HAD PLANNED C-SECTION MAIN OR FOR PREVIA, POSSIBLE ACCRETA. NO ACCRETA FOUND DURING CASE AND PATIENT MOVED TO L&D PACU (LABOR AND DELIVERY POST-ANESTHESIA CARE UNIT). AFTER 30 MINUTES IN PACU, PATIENT BEGAN HEMORRHAGING AND WAS MOVED TO OR B. PT WAS HEMODYNAMICALLY UNSTABLE AND DECISION FOR HYSTERECTOMY WAS MADE; PATIENT WAS PUT UNDER GENERAL ANESTHESIA. NO COUNT WAS PERFORMED BEFORE HYSTERECTOMY INCISION D/T EMERGENT NATURE OF CASE. ON FIRST X-RAY, A SMALL "RIBBON-LIKE" BAND WAS NOTED ON PATIENT'S LEFT ABDOMEN. FIRST READ WAS EXTREMELY DELAYED DUE TO LACK OF RADIOGRAPHER. MDS CALLED FOR SECOND X-RAY WHICH WAS EXTREMELY DELAYED DUE TO LACK OF TECH. UPON SECOND READ, IT WAS DETERMINED THE RIBBON WAS CAUSED FROM THE STITCHING OF THE HOVERMAT UNDERNEATH THE PATIENT. X RAY WAS FOUND TO BE CLEAR ONCE HOVERMAT STITCHING WAS CLEARED FROM UNDERNEATH PATIENT. IT WOULD BE MY RECOMMENDATION TO STREAM THE PROCESS OF A RADIOLOGY READ WHEN IN SURGERY AND ALSO TO NOTIFY STAFF THAT OUR HOVERMAT STITCHING DOES APPEAR ON X-RAY SO THE PLACEMENT SHOULD BE CHECKED PRIOR TO AN X-RAY. THERE WAS NO DEFECT IN THE PRODUCT THAT CAUSED HARM, HOWEVER THERE IS A SAFETY CONCERN IN THAT THE STITCHING OF THE HOVERMAT SHOWS UP ON X-RAY. WE HAD A PATIENT UNDERGO AN X-RAY WHILE LAYING ON TOP OF THE HOVERMAT WHEN A SMALL RIBBON-LIKE BAND WAS NOTED IN THE PATIENT'S ABDOMEN. ON SECOND READ OF THE X-RAY, IT WAS DETERMINED THAT THE RIBBON-LIKE BAND WAS CAUSED FROM THE STITCHING OF THE HOVERMAT. ONCE THE HOVERMAT WAS REMOVED AND A REPEAT X-RAY WAS TAKEN, THERE WAS NO LONGER A RIBBON-LIKE BAND IN THE ABDOMEN. THE REQUEST IS FOR CLARITY ON WHETHER THE MANUFACTURER IS AWARE THAT THE STITCHING IN THE HOVERMAT SHOWS UP ON X-RAYS OR IF THIS WAS A BAD BATCH.