A surgeon left a blue vinyl device more than 10 inches long inside a patient during hernia surgery over the summer at St. Joseph Hospital in Eureka, according to the California Department of Public Health.
The blunder increased the odds of the patient developing other medical problems or even dying, and it forced doctors to do a second surgery, according to a state deficiency finding released to the North Coast Journal late Tuesday afternoon.
The episode "caused or was likely to cause serious injury or death," and it violated state rules that require hospitals to follow procedures to keep track of all items placed in a patient's body during surgery, the state report said.
The hospital had no immediate comment, but Laurie Watson-Stone, its vice president for ancillary and support services, said she and other St. Joe's officials would try to respond in more depth on Wednesday.
The state deficiency report blanks out details including the surgeon's name, the patient's name and her current condition. It said the problem was discovered two months later, after the patient kept complaining of ongoing pain and her surgeon ordered a CT scan.
The woman had undergone surgery to repair an abdominal hernia. During the procedure, her surgeon used a visceral retainer, sometimes called a "FISH," to hold the bowels out of the way, the state said. The retainer is a flat, blue vinyl device, shaped a little like a flounder, 10 inches long and as much as 6.5 inches wide at its widest spot, the state report said.
While most dates in the report are blanked out, one reference to June 8 surgical records suggests the first operation might have occurred that day. The second operation or the CT scan might have occurred on July 29, which is when St. Joe's reported to state regulators that a foreign object had been left inside a patient's body.
The state investigation found that because the "fish" wasn't always used in hernia surgeries, it was sometimes brought into the operating room late and was not routinely included in a count of instruments made before and after surgery.