A patient at an ACT hospital recently required a second operation after medical staff left a surgical instrument inside the person's abdomen, documents reveal.
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The incident, described as a ''catastrophic'' mistake in internal ACT Health documents, sparked an education session for staff to make sure they understood the policy for keeping track of instruments during surgeries.
Audits were also done to reduce the risk of a similar error but ACT Health refuses to reveal which instrument staff left inside the patient.
The patient was admitted for an emergency laparotomy - a large cut made to access the abdominal cavity which contains a number of organs including the liver, pancreas, spleen and kidneys - which is when the blunder was made.
It is not clear at which hospital the mistake was made.
The documents obtained by The Canberra Times outline mistakes made at The Canberra Hospital and Calvary Hospital from July 2011 to July 2012 and also reveal information about:
■ Two deaths in ACT hospitals in the same period have been labelled catastrophic. The deaths of these patients were classed as being unrelated to the natural course of illness and differing from the immediate expected medical outcome.
■ Two ''near misses'' where too much medication was given to patients, one of whom was given 50 times too much sedative.
■ A surgery done on the wrong side of someone's body, the second case of its kind in the ACT in 18 months.
■ A failure to follow correct guidelines was found when a patient was given another patient's blood, a mistake which did not adversely affect the person given the transfusion.
An ACT Health spokesman said the number of adverse incidents occurring was minuscule when compared with the thousands of procedures performed each year. The Health Directorate did 18,219 surgical procedures in 2011-12.
One of the two deaths described in the documents involved an unrecognised oesophageal intubation.
According to medical references, this mistake occurs when a tube goes into the oesophagus, which leads to the stomach, rather than the windpipe. In the second death referred to in the documents, staff were considering whether to retrospectively refer the patient's death to the coroner. The patient - located in a women, youth and children's ward - had suffered from a condition related to fluid around the heart.
In terms of over-medication cases, the documents say one ''near miss situation'' involved a patient transferred to the ACT from a regional hospital who was given 50 times too much of a fast-working sedative.
The staff member who gave 25 milligrams of Midazolam to the patient instead of 0.5 milligrams was traumatised by the error which happened when the sedative needed to be administered quickly.
''It seems the error occurred due to communication about the volume of the medication,'' her supervisor wrote in an internal report.
In a second medication mix-up, a patient was intravenously given 10 times too much paracetamol.
The internal ACT Health documents suggest an administrative error was to blame for surgery being performed on the wrong side of a patient's body.
In a case reported late last year which is now before the ACT Supreme Court, it was revealed an elderly woman, Lima Thatcher, allegedly had an operation on the wrong hip at the start of 2011.
