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The One That Got Away – Patients Often Exit Surgery With “Retained Surgical Items”

By: staff.writer October 5, 2012 no comments

The One That Got Away – Patients Often Exit Surgery With “Retained Surgical Items”

As patients, we rely on our health care professionals for our safety and well-being, no more so than when we have to undergo a surgical procedure.  Yet, according to a recent New York Times article nearly 4000 patients leave the operating room with a “retained surgical item”, what should be a preventable medical error.  The items left behind in the patient’s body such as clamps, scalpels, needles, and surgical sponges, are a surgical patient safety problem which can cause infections and other complications and in severe cases even death.  According to the 1999 study by the Institute Of Medicine, nearly 98,000 deaths occur annually because of preventable medical error.

The Times article details the case of how a Kentucky woman’s excruciating abdominal pain prompted a CT scan which revealed the presence of a surgical sponge left behind by the surgeon who performed her hysterectomy four years earlier.  Over the span of time, the sponge had adhered itself to her bladder, stomach area, and walls of the abdominal cavity.  The sponge spread an infection which resulted in the removal of a large part of intestine.  The sponge is gone, but its effects have destroyed her way of life, suffering from severe bowel issues and unable to work.

Of the numerous items that are inadvertently ‘left behind’, sponges account for approximately two-thirds.  In this day and age it is hard to fathom that these type of errors are still occurring, yet many do because surgical teams are still relying on “old-fashion methods” to account for all of their equipment.  New technologies such as RF tags and barcoding can assist surgical teams in tracking surgical sponges, but many are still relying on the traditional method of surgical nurses counting and recounting the sponges used for the procedure.  When the operating room becomes busy or chaotic, miscounts can occur and the patient is left at risk.

[important title= “NYT: No Sponge Left Behind”]“In most instances, the patient is completely helpless,” said Dr. Gibbs, who is also the director of NoThing Left Behind, a national surgical patient safety project. “We’ve anesthetized them, we take away their ability to think, to breathe, and we cut them open and operate on them. There’s no patient advocate standing over them saying, ‘Don’t forget that sponge in them.’ I consider it a great affront that we still manage to leave our tools inside of people.[/important]

Although the technology is available to assist surgical teams and act as an added safety measure against the occurrence of retained surgical items few hospitals actually implement it – and cost and profits could be the culprit.  Implementing new tracking technologies such as the RF Assure system which uses tiny radio frequency tags attached to each sponge adds approximately $10 to the cost of each procedure.  Cited in the article, Dr. Berto Lopez, an obstetrician-gynecologist and chief of the safety committee at West Palm Hospital in West Palm Beach, FL stated that “fewer than 1 percent of hospitals employ it … In my heart, I think it comes down to hospitals not wanting to spend the 10 bucks.”   Ten dollars seems like it should be a small price to pay for the bigger payoff of quality patient outcomes.

If you have suffered injuries from a preventable medical error or medical malpractice, contact us today for a free case consultation with an experienced medical malpractice attorney.


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