Patient forced to undergo open heart surgery after broken wire left in artery following insertion of stent in HK’s Grantham Hospital

30-Apr-2019 Intellasia | South China Morning Post | 6:00 AM Print This Post

A 60-year-old man had to go through open heart surgery after a broken wire left in his artery from a procedure about two weeks earlier was found to be “longer than estimated”, Hong Kong’s Hospital Authority disclosed on Saturday.

The patient was originally admitted to Grantham Hospital in Wong Chuk Hang in mid-April for percutaneous coronary intervention, a non-surgical procedure to open up arteries of the heart by inserting a stent into the blocked vessel.

The insertion was successful but when the clinician retrieved the coronary guide wire it was found to be broken and a segment was discovered in the artery.

At the time, the clinician considered it unnecessary to remove the wire and told the patient and his family about the complication and a follow-up plan.

However, following a review of the procedure and a study of the recorded video, the hospital’s clinical team suspected the retained wire was longer than the original estimation.

The authority did not specify the wire’s length in its report and declined to provide further information when asked by the Post.

On Friday, the patient was sent to Queen Mary Hospital in Pok Fu Lam for an interventional procedure to retrieve the wire but the attempt failed.

“After consultation with [the hospital's] cardiothoracic surgeons, a clinical decision was made to proceed to an open heart surgery immediately to retrieve the broken wire,” the authority said.

Following surgery the patient was admitted to the intensive care unit.

Grantham Hospital apologised to the man.

“The hospital will review the case to ensure service standards and patient safety,” the authority said.

According to the authority’s latest risk alert newsletter issued on Friday, retained instruments and materials were the most frequently reported sentinel events last year, accounting for 12 of 27 incidents.

The risk alert newsletter issued in July 2018 included tips on preventing retained guide wire. They included controlling the wire end to ensure it was always visible and counting the used wire before ending the procedure.

In the latest newsletter, Dr Lau Chor-chiu, chief executive of hospitals in Hong Kong East, wrote: “If we go back to basic training, one will recall the fundamental principle of ‘not to allow disappearance of the tip of the guide wire’. If the operator follows this principle, incidents of retained guide wire will not happen.”


Category: Hong Kong

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