Practising doctor and lawyer Dr Virginia Lowe discusses a CT scan of one of her clients, which shows a mass that turned out to be wadded-up surgical gauze mistakenly left inside him during a routine biopsy. — TNS
When a surgeon accidentally leaves a surgical tool inside a patient’s body after a procedure, the harm can be severe.
The patient can suffer from life-threatening infections, organ damage and an additional surgery to remove the object.
This type of medical error is extremely rare, but it does happen.
For example, an investigation by The Philadelphia Inquirer identified 203 cases in which patients at 39 Philadelphia-area hospitals in the United States received treatment related to a surgical item accidentally left inside their bodies during a procedure.
This was according to an analysis of Pennsylvania hospital billing records from 2017 through 2022.
Patient safety experts say a single case is one too many.
Government health regulators call these medical errors “never events” because they should never happen.
Sponges used to sop up blood during surgery are the most common item erroneously left inside patients.
Another frequently-missed item is a broken catheter fragment, said Dr Marcus Schabacker, president of ECRI, a US national non-profit organisation aimed at improving patient safety based in Pennsylvania, US.
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Safety protocols
Dr Schabacker, who is himself an anaesthesiologist and intensive care specialist, is not your typical patient.
He prefers to stay awake under local anaesthesia and watch to make sure surgical teams don’t mistakenly leave catheter parts or other objects behind.
“If you are conscious, you can say, ‘Hey, did you remove the whole thing?’” he said.
Most patients don’t stay awake during surgery, but can still take steps to protect their own safety.
For example, Dr Schabacker recommends that patients familiarise themselves with the safety measures that hospitals employ to prevent objects being left behind, and talk to their surgeon before the procedure about which protocols will be followed.
The Philadelphia Inquirer spoke with Dr Schabacker and Philadelphia-based health system Temple Health chief medical officer Dr Carl Sirio, about some of those safety measures:
A designated operating room (OR) staffer – typically a nurse – counts all items.
This includes a count of sponges and instruments before, during and after the procedure (but before closing the incision).
Surgical protocols include arranging surgical instruments carefully on trays, with each in a designated spot where it must be returned after a surgeon uses it and hands it back.
Surgical teams should also have a “time out” before and after the procedure to confirm that counts are correct and that all items are accounted for.
For all counts, one nurse should count aloud, as two other OR staffers watch.
Typically, an OR has a “circulating nurse” to help provide oversight.
All used and counted items should ultimately be placed into a designated container.
In addition, staff should count supplies in bundles of 10 to reduce the likelihood of a miscount.
Dr Schabacker, however, noted that manual counts are time-consuming and more prone to mistakes, with an accuracy rate of 75% to 80%.
Many US hospitals use sponges, towels and other supplies with special tags that emit a radio frequency that can be detected with a special device.
This is much like a security tag on clothing that will sound a security alarm if not removed at the register.
Staff can use a handheld device to scan a patient’s body to check for these tagged surgical items.
“It’s very, very effective, but it’s not cheap,” Dr Schabacker said.
“You need proprietary gauzes and sponges and other materials.”
A cheaper alternative is a computer-assisted barcoding system.
Every sponge, piece of gauze or other surgical tool gets barcoded and scanned before it’s used.
A nurse scans the barcoded object again using a handheld device when it is handed back.
A computer tracks the count, which is displayed on a screen.
The barcode scanner has about a 97% detection rate, according to Dr Schabacker.
If an item remains missing after other safety checks are completed, an X-ray should be taken while the patient remains on the table.
A radiologist should read the X-ray immediately.
This approach is more expensive, but has a high detection rate.
An X-ray is a good option for high-risk surgeries, such as long procedures with multiple surgical teams, Dr Schabacker said.
Each hospital should have a universal protocol carried out “in every room, every day, every case”, said Dr Sirio.
Hospital administrators should also foster a culture in which nurses and other OR staff feel comfortable speaking up if a surgeon breaks protocol or tries to take a shortcut.
Likewise, patients should be encouraged to advocate for themselves if something doesn’t feel right after the procedure. – By Wendy Ruderman and Sarah Gantz/The Philadelphia Inquirer/Tribune News Service
