Leaving foreign objects in the body after surgery is called a “never event” — a mistake so preventable that it should never happen if basic procedures are followed. The sad fact, however, is that “never events” do happen, and this one can cause pain, physical injuries, infections and even death.
The Joint Commission, one of the nation’s preeminent healthcare safety and accreditation organizations, recently released a report on the frequency of surgical items being left behind — and the news wasn’t good.
The Commission found 772 reported incidents between 2005 and 2012 in which surgical teams failed to remove sponges, needles, retractors, surgical instruments and other items after procedures. 16 patients are known to have died and, 95 percent of affected patients needed further hospitalization.
Unfortunately, the objects are not always found right away. One patient, a nurse, profiled in the report learned that a sponge had been left her body only when she became seriously ill four years later. By then, the sponge had adhered to her bladder and the walls of her abdominal cavity.
Although hospitals have been warned again and again to eliminate this problem, the main reason items get left behind after surgery is simply that many hospitals lack the policies and procedures that can prevent it. And, when they do, those procedures are often ignored.
Surgeons and their teams often rely on their own systems, such as counting all sponges in and out, or manually sweeping the patient’s body for missed objects. The report found, however, that in about 80 percent of the cases where surgical sponges were missed, the surgical team thought they had counted them out correctly.
Since those methods are too subject to human error, hospitals may be negligent in allowing their use. Instead, the Commission recommends that hospitals adopt mandatory, standardized systems that involve two people doing the counting and a whiteboard to record it. Every member of the team should feel responsible for an accurate count — and speak up.
Before the surgery begins, a nurse or a surgical technician should count all of the equipment, write that count on the white board, and have the surgeon verify it. Another should occur before the patient’s body is closed, and a third when the procedure is over. The Commission says that this system succeeded in reducing errors by 50 percent at one children’s hospital after only one year.
Source: CBS News, “Nearly 800 surgical tools left in patients since 2005: Report,” Ryan Jaslow, Oct. 18, 2013