Queen Elizabeth Hospital (QEH) has recently reported sentinel events of retained metal stylet in two cancer patients’ bodies to the Hospital Authority Head Office (HAHO). The events happened after QEH introduced a new model of implantable long-dwelling catheter in 2016. Metal stylets were left in the two patients’ bodies following a surgical procedure carried as part of their chemotherapy treatment. QEH said the errors had not affected the patients’ treatment outcomes – and both have been discharged from the hospital after the removal.

Retained stylets detected through routine X-Ray review


The introduction of the new catheter was to facilitate continuous and repeated drug infusion for patients. Under the new procedure, the inner metal stylet for supporting the catheter should be removed after the insertion of the catheter.

According to Hospital Authority (HA)’s information, the first patient identified had previously undergone two surgical procedures in 2016 and 2017. During the surgeries, catheters were inserted through the left side and right side of the patient’s neck respectively into the superior vena cava for chemotherapy.

QEH later conducted a routine review of the patient’s X-Ray images, and discovered leftover metal parts in the patient’s body. A segment of metal stylet was retained in the patient’s right heart region, while another metal stylet inserted through the patient’s left neck was not removed.

Promptly responding to the incident, QEH has arranged a check-up and an immediate removal of the metal parts for the patient. The hospital also reviewed the X-Ray images for five other patients, who had undergone a similar catheter placement procedure. It was from this review, where the hospital detected a second cancer patient who also had the metal stylet left behind inside the catheter.

No further details about the first and second patient were provided by the hospital. Nevertheless, both patients and their families had been contacted, followed-up and fully informed of the situation.

Further investigation: HA set up Root Cause Analysis (RCA) panel to look into the incidents


In response to the incident, HA has set up a RCA panel to investigate the errors. The panel is expected to submit a report of the incident to HAHO in eight weeks. HA has also released a press release on 6 July – acknowledging it had received reports from QEH regarding the two incidents.

“The hospital is very concerned about the safety of both patients and medical products and will contact the manufacturer for further information,” asserted a HAHO spokesperson.

On top of QEH’s immediate action to follow up and treat the affected patients, HAHO’s Quality and Safety Division has issued a safety alert to remind all hospitals carrying out the new catheter procedure to be alert and review practice in completing the new procedure. MIMS

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Sources:
http://www.scmp.com/news/hong-kong/health-environment/article/2101647/two-cancer-patients-had-small-metal-parts-left
http://www.ha.org.hk/haho/ho/pad/170706Eng.pdf