Delayed Diagnosis of Retained Surgical Gauze, as a Medical Error: A Case of Hip Septic Arthritis Management and its Differential Diagnosis

Abstract

An intra-articular infection in children is paediatric septic arthritis (SA). It is the most typical septic joint condition during growth, which is regarded as an orthopaedic emergency. Treatment options include antibiotic therapy and surgical management. Leaving supplies unintentionally in the surgical area is called retained surgical foreign bodies (RSFBs). They are rare but with serious complications. This case report presents a 14-year-old boy who underwent surgical evacuation due to a SA diagnosis. He experienced persistent pain for about 5 months after surgery, which led to the discovery of a retained sterile gauze. This case presents critical medical errors, including: Retention of sterile gas during surgical intervention, lack of manual counting of surgical items after the procedure and inadequate imaging assessment during and post-surgery. RSFB often results from communication failures. We discuss the diagnostic challenges of this case and indicate the importance of safety protocols, including manual counting of surgical items and imaging assessments, to prevent and diagnose these errors.