Description of Event or Problem · 0
EVENT DESCRIPTION: A PATIENT INDUCED FOR INDUCTION OF LABOUR (IOL) WITH 5 DILATORS INSERTED, DURING REMOVAL ONLY 4 DILATORS REMOVED, ONE DILATOR MISSING. THE HEALTHCARE PROFESSIONAL (HCP) DECIDED NOT TO PERFORM AN ULTRASOUND SCAN. BABY DELIVERED VIA CS (REASON: MATERNAL REQUEST), CAVITY EMPTY, THE MISSING DILATOR WAS NOT FOUND. NO SCAN PERFORMED POSTNATALLY, THE PATIENT WAS DISCHARGED HOME - THE HCP PROBABLY ASSUMED THE DILATOR MUST HAVE FALLEN OUT PRIOR TO REMOVAL. THE MISSING DILATOR PASSED AT HOME AROUND 2 DAYS LATER AS REPORTED BY A COMMUNITY MIDWIFE DURING POSTNATAL CHECK OF THE PATIENT. THE PATIENT WAS WELL, NO SIGNS OF INFECTION. CONCLUSION OF INVESTIGATION: THE HCP WRONGLY ASSUMED THE MISSING DILATOR MUST HAVE FALLEN OUT PRIOR TO REMOVAL. NEITHER ULTRASOUND SCAN WAS PERFORMED WHEN MISSING THE DILATOR (1 OF 4) AFTER REMOVAL NOR POSTNATALLY, ALTHOUGH IT IS A RECOMMENDED PROCEDURE FOR CASES WHEN THE DILATOR HAS SOMEHOW MIGRATED OR BEEN DISPLACED OUTSIDE CERVICAL CANAL. THE REASON FOR REPORTING IS THE POTENTIAL RISK OF INFECTION WHEN THE PATIENT WAS DISCHARGED HOME WITH THE DILATOR IN HER BODY (SIGNIFICANTLY LONGER THAN 24 HOURS).