You are an NP in a small hospital and you are reviewing the chart of a patient who underwent a second abdominal surgery. Six months after his initial surgery, the patient had to return to surgery for removal of a retained surgical instrument, an 11-inch retractor. On his follow-up appointment, your review of his medical record reveals that the discharge diagnosis for his second surgery was abdominal adhesions and there is no mention of removing the retractor in the surgical report.

As you review his chart, you question whether the incident was reported as a

“never event.” You practice in a state that has mandatory reporting of never events.

a. What ethical dilemmas do you identify in this scenario?

b. What legal issues do you identify in this scenario?

c. What action do you recommend?

d. How do you justify this action based on legal and ethical guidelines?