AUGUST, 2015

Failure to assess risks
Lack of planning and follow up
Avoidable deteriation and re admission

Rushed, poorly managed discharge planning resulted in a serious error being missed

A young woman had a dilatation and curette at a hospital. During the procedure, her uterus was unintentionally perforated. The surgeon was aware of this error, but it was not clearly explained to the patient.

She was discharged early the following day in a rush, as the hospital needed to free up it’s beds.

There was no discussion of potential problems to watch out for. No GP or nursing follow-up was organised.

A few days after surgery, the woman developed a fever. Her abdomen became hard and swollen. She felt very unwell and contacted her friends. They took one look at her, and called an ambulance.

She was rushed back to the Emergency Department. Her temperature was 40 and her skin was flushed.

A physical exam, CT of the pelvis and blood tests were done. The woman was diagnosed with a severe infection in her abdomen called peritonitis. She was rushed to theatre for emergency surgery.

Surgeons found the small nick into her bowel, which had caused faecal matter to slowly leaking into her abdomen cavity.

It was entering her blood stream, causing septic shock. The surgical team had to physically move her bowel from her abdomen cavity, wash it all down, find the nick and suture it up, then replace the bowel back in her abdomen. She was given strong antibiotics.

After theatre she was taken to Intensive Care and treated for septic shock. She was sent to a ward after two day. She then spend several weeks in hospital with open abdomen drains, regular and painful dressings and continuous intravenous antibiotics.

There was no connection made between the patients readmission and the original surgical error. Her surgeon did no have to explain how the problem had occurred.

The hospital did not suffer any fine or penalty for a patient being readmitted so quickly after a discharge. No action was taken to prevent this error from recurring. No apology was given to the woman.

© Wikihospitals 2015