Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.
A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.
McCook A. Preventing medication errors at small and rural hospitals. Pharmacy Practice News. May 6, 2020.
ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25.