Surgical errors: leaving sponges and other objects behind
Why do surgical teams so often leave sponges and other objects behind after an operation?
There is no doubt that it happens a lot. According to a recent study, items such as sponges have left behind in patients an average of 39 times per week nationally. That adds up to about 2000 times a year.
The study by researchers at the Johns Hopkins University School of Medicine was based on an analysis of judgments and settlements in medical malpractice cases.
According to national quality standards, “unintended retention” of a sponge or other foreign object in a patient after surgery or some other procedure is a “never” event. Never events are unambiguous, serious, and usually preventable.
The National Quality Forum lists unintended retention as one of five surgical events that are defined as “never” events. The others include surgery on the wrong body part, surgery on the wrong patient, and the wrong type of surgery.
So why does this keep happening so much? Many experts believe that the answer involves the lack of sound procedures to prevent hospital errors.
For example, relying solely on individual doctors and nurses to always maintain the right count of foreign objects inserted into a patient during surgery is not sufficient protection against errors. A more effective approach is to use a procedure whereby every sponge or other object is put in a certain holder after the surgery. If a place in the holder was expected to be filled but is not, that is an indicator of a missing object that may have been left behind in the patient.
Hospital culture could improve by making sure all members of a surgical team feel empowered to speak up if something seems wrong. For too long, the hospital hierarchy has been so dominated by doctors that communication breakdowns occur too easily.
Source: “Medical field words to reduce the number of surgical mistakes,” Los Angeles Times, Anna Gorman, 12-23-12
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