Description of Event or Problem · 1
PT WAS SCHEDULED FOR AN EXPLORATORY LAPAROSCOPY. THE EXPLORATORY LAPAROSCOPY REVEALED A RUPTURED ECTOPIC PREGNANCY. PT STARTED TO HEMORRHAGE SO PT WAS OPENED. NO INSTRUMENT COUNT WAS DONE BEFORE PT WAS OPENED; HOWEVER, A SPONGE AND LAP COUNT HAD BEEN DONE BEFORE THE BEGINNING OF THE PROCEDURE. AT THE END OF THE PROCEDURE ABDOMINAL X-RAY WAS REQUESTED BY THE RN CIRCULATOR. AGREED TO THE X-RAY, X-RAY REVEALED WHAT APPEARED TO BE A DISK IN THE LEFT LOWER QUADRANT OF THE ABDOMEN, AND THE RN CIRCULATOR CHECKED THE LINENS, UNDER THE PT AND FOUND NO DISK. ANOTHER X-RAY WAS TAKEN AND THE DISK APPEARED TO HAVE MOVED FARTHER TO THE LEFT OF THE ABDOMEN. AT THIS POINT, ALL ECG LEADS WERE REMOVED FROM THE PT. ANOTHER X-RAY (THIRD) REVEALED THE DISK WAS STILL HERE. PT WAS THEN PREPPED AND OPENED FOR AN EXPLORATORY. ONCE IN ABDOMEN, THE SURGEON WAS UNABLE TO LOCATE A DISK. ORDERED A C-ARM FOR DIRECT FLUOROSCOPY AND DISK WAS NOT SEEN. DR REQUESTED THE PRESENCE OF DR FOR CONSULTATION. DR REQUESTED A COMPLETE FLUOROSCOPY OF THE ABDOMEN. NO DISK WAS SEEN. BOTH PHYSICIANS AGREED THAT THERE WAS NO DISK IN THE ABDOMEN. PT WAS CLOSED AND TRANSPORTED TO PACU. FOLLOWING THE PROCEDURE, THE OR TABLE PAD WAS TAKEN TO RADIOLOGY AND THE DISK WAS NOTED IN THE PAD.