Surgical Error Leaves Woman with Half a Kilo of Bandage Inside Her Abdomen

Stockholm, Sweden – August 5, 2025 – A Swedish clinic is facing scrutiny from the Inspection for Health and Care (IVO) after a patient discovered a significant amount of surgical bandage had been left inside her abdomen following a cesarean section.

The incident occurred in the summer of 2022. The patient underwent an emergency cesarean section and experienced severe post-operative bleeding. Medical staff successfully controlled the hemorrhage using a compression balloon and two surgical cloths placed in the vagina.

However, upon discharge after several days of care, one of the surgical cloths – weighing approximately half a kilogram – remained inside the patient’s abdomen. The error was onyl discovered when the woman herself noticed symptoms and sought further medical attention.

Patient Reports Loss of Trust

According to a report submitted to IVO, the patient expressed profound concern, stating a gynecologist who discovered the retained bandage remarked on the potential for catastrophic consequences had it remained undetected for a longer period. “He said ‘What would have happened if it was here for a month?’ I think it would have been a disaster!” she wrote.

The patient further stated that the incident has resulted in a significant loss of confidence in the healthcare system.

IVO has issued a critical assessment of the clinic’s handling of the case, citing a failure in post-operative procedure. While the case is now closed, IVO will monitor the clinic’s implementation of corrective measures to prevent similar incidents in the future.

Understanding Retained Surgical Items (RSIs)

Retained surgical items (RSIs) – sponges, instruments, or other materials inadvertently left inside a patient’s body after surgery – are a recognized, though thankfully rare, medical error. According to studies, RSIs occur in approximately 1 in 5,700 to 1 in 15,000 surgeries. While advancements in surgical techniques and counting protocols have reduced their incidence, they remain a serious patient safety concern.

Preventing RSIs: A Multi-faceted Approach

Hospitals employ several strategies to minimize the risk of RSIs, including:

• Surgical Counts: Rigorous counting of sponges, instruments, and sharps before, during, and after surgery.
• Radiopaque Markers: Using sponges and materials containing radiopaque markers, allowing them to be detected on X-rays.
• Standardized Protocols: Implementing clear, standardized procedures for handling surgical materials.
• Communication: Effective communication among the surgical team.
• Technology: Utilizing technologies like radio-frequency identification (RFID) tags to track surgical items
  
  

  What systemic changes could [Clinic Name Redacted for Privacy] implement to move beyond individual blame and address the root causes of retained surgical sponges?

  Clinic Loses Half a Kilo of Bandages in Women’s Abdominal Procedures: A Deep Dive

  The Unexpected Complication: Retained Surgical Sponges

  The revelation of retained surgical sponges – specifically, a meaningful mass totaling half a kilogram of bandages – following women’s abdominal procedures at a [Clinic Name Redacted for Privacy] has sent ripples through the medical community. This isn’t simply a matter of misplaced materials; it’s a serious patient safety issue with possibly devastating consequences. Retained surgical items (RSIs), including sponges, gauze, and instruments, are a recognized “never event,” meaning they should never occur. This incident highlights vulnerabilities in surgical protocols and the critical need for robust preventative measures.Terms like surgical errors, medical negligence, and patient safety are central to understanding the gravity of this situation.

  Understanding the Risks of Retained Surgical Sponges

  Retained surgical sponges pose a multitude of risks to patients undergoing abdominal surgeries like hysterectomies, cesarean sections, and abdominal repairs. These risks escalate with time:

  Infection: The most common complication. Foreign bodies like sponges provide a breeding ground for bacteria, leading to localized or systemic infections.Post-operative infection is a key search term here.

  Abscess formation: Encapsulation of the sponge by inflammatory tissue, creating a painful and potentially life-threatening abscess.

  Adhesions: Scar tissue forming around the sponge, potentially causing bowel obstruction, chronic pain, and infertility. Surgical adhesions are a significant long-term concern.

  Organ Damage: Migration of the sponge can lead to perforation or damage to surrounding organs.

  Chronic Pain: Even without other complications, the presence of a foreign body can cause persistent discomfort. Chronic abdominal pain is a common patient complaint.

  How Could This Happen? Examining Potential Protocol Failures

  Several factors can contribute to retained surgical sponges. The [Clinic Name Redacted for Privacy] incident is currently under investigation, but common contributing factors include:

  Inadequate Sponge Counts: The cornerstone of RSI prevention is meticulous sponge counting before, during, and after surgery. Discrepancies must be resolved before wound closure.

  Dialogue Breakdown: Poor communication between surgical team members (surgeons, nurses, surgical technicians) regarding sponge counts and location.

  Emergency or Urgent Cases: High-pressure situations can lead to shortcuts and compromised protocols. Emergency surgery complications are often higher.

  Complex Anatomies/Obesity: Tough surgical fields can increase the risk of sponges being inadvertently left behind. Bariatric surgery complications often require extra vigilance.

  Changes in Surgical Team: Introducing new personnel mid-surgery can disrupt established routines.

  Fatigue: Long surgical shifts can impair concentration and increase the likelihood of errors.

  The Role of Technology in Prevention: RFID and Barcoding

  Fortunately, advancements in technology are offering solutions to mitigate the risk of rsis.

  RFID (Radio-Frequency Identification) Sponges: These sponges contain microchips that can be tracked using a scanner, providing a real-time count and location. This is considered the gold standard in RSI prevention. RFID surgical sponges are gaining traction.

  Barcoded Sponges: Similar to RFID, barcoded sponges allow for scanning and tracking, though they require a line of sight for the scanner.

  Surgical Safety Checklists: The World Health Organization (WHO) Surgical Safety Checklist is a standardized tool designed to improve communication and reduce errors. WHO surgical checklist implementation is crucial.

  Legal Implications and Patient Rights

  Patients who experience complications due to retained surgical sponges have legal recourse. This typically falls under the umbrella of medical malpractice. Key elements of a triumphant claim include:

  Duty of Care: The clinic and surgical team had a duty to provide competent medical care.

  Breach of Duty: the clinic or surgical team failed to meet the standard of care (e.g., inadequate sponge counts).

  Causation: The breach of duty directly caused the patient’s injuries.

  Damages: The patient suffered quantifiable damages (medical expenses, lost wages, pain and suffering).

  Patients have the right to:

  Full Disclosure: Be informed of the incident and its potential consequences.

  Medical Records: Access their complete medical records.

  Independent Medical Evaluation: Seek a second opinion from another physician.

  Legal Counsel: Consult with an attorney specializing in medical malpractice. Medical malpractice lawyer searches are common after such events.

  Case Study: Similar Incidents & Lessons Learned

  While the [Clinic Name Redacted for Privacy] case is recent, it’s not isolated. In 2018, a hospital in Lincoln, Nebraska, faced a similar situation, resulting in a multi-million dollar settlement. These cases consistently demonstrate the importance of:

  1. Systemic Change: Addressing the root causes of RSIs, not just blaming individual errors.