Swab left in Sheffield patient’s eye for three months after cataract operation

The Hallamshire Hospital
The Hallamshire Hospital
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A Sheffield patient was left with a 4mm swab in their eye for three months after a cataract operation.

The mistake involving the patient’s left eye was only discovered after she returned to the Hallamshire Hospital for a second operation on their right eye and complained to surgeons of the pain she had been experiencing.

Details have been revealed in a report to the governing body of Sheffield NHS Clinical Commissioning Group.

Sheffield Teaching Hospitals Foundation Trust has apologised for the error and said steps have been put in place to prevent such a mistake happening again.

The report to the CCG said a 4mm swab called a Mydriasert had been inserted into the patient’s eye before surgery to dilate the pupil.

It said the removal of the swab had not formed part of a formal check process at the end of the operation – a situation now rectified.

The report said actions have now been taken to change processes at the hospital for such operations.

It said: “The ophthalmic insert was accidently left in situ because it did not form part of a formal check process that is verbalised to all the team.

“The removal of the Mydriasert by the theatre personnel now requires verbal and visual confirmation with the scrub practitioner.

“It is now an integral part of signing that the surgical count is correct.

“If the Mydriasert cannot be removed, or is not found, the surgeon is required to undertake an additional examination and verbally confirm it is not retained.”

Dr David Throssell, Medical Director at Sheffield Teaching Hospitals, said: “We carry out thousands of eye operations every year successfully, but on the rare occasions when a mistake is made we take this very seriously.

“In this instance a patient who came in for a follow-up operation was found to have a tiny soft capsule left in her eye which should have been removed following surgery a few weeks before.

“This has not caused any harm to the patient and was removed without any problems.

“We immediately apologised and explained to the patient what had happened.

“Since then we have made changes to the post-operative checklist to limit the chances of this happening again.”