Any surgical towels, sponges or medical devices left inside a patient causing infection, septic shock or even death is a good cause for concern at hospitals and surgical centers in Virginia (VA), North Carolina (NC) and nationwide. These are “never events.” It should never occur with proper procedures. According to Science Daily, an estimated 1500 surgical objects such as sponges, towels and medical tools are sewn up inside patient bodies each year. Any good hospital risk management program realizes that a surgical towel, surgical sponge, or surgical device, sewn up inside a patient is a "never event." Our law firm injury lawyers have previously published several articles covering the medical malpractice issue of surgical sponges/devices left in patients:
So, if a company comes along with a method to significantly reduce the chances that a surgical sponge, surgical towel or surgical device will be left inside a patient’s body, any conscientious hospital should pay attention. As Virginia/Carolina medical malpractice lawyers, we know that the more simple the preventive remedy, the more likely a jury will find that a hospital or doctor was careless, especially in sponge/towel cases simply left inside a patient’s body leading to infection, increased medical expenses/care or even death. The cause is virtually always human error, where the nurses and doctors lose proper count of the sponge/towel count or fail to properly account for a medical tool. Sometimes, a medical tool breaks and is left inside the body, which may be a different cause, but the outcome can be devestating injuries.
A company called Surgicount Medical has introduced surgical towels embedded with a bar code, and an associated bar code wand, which can be mounted to a movable rack, and the system counts in and counts out the surgical sponges. This system has now been introduced at the Mayo Clinic, and the hospital is reporting that the computerized count system is definitely reducing these “never events” with little additional time or effort of the medical personnel.
Surgicount notes that studies show 88% of cases with retained foreign bodies involved a final count that was erroneously thought to be correct. The root cause of retained cases is usually not an inability to find a lost sponge, but not knowing that a sponge needed to be searched for. Surgicount’s system has three parts:
- A comprehensive line of uniquely identifiable surgical sponges and towels (Safety-Sponges)
- Touch-screen scanning devices (SurgiCounters)
- A networked database application (Citadel) that allows for the complete review, management and analysis of the count reports generated
Essentially, the staff still keep notes of a manual count in and count out, but the bar code system serves as the double check-and a more reliable one at that.
“In about one in 5,000 operations there is some type of retained object," said Dr. Robert Cima with the Mayo Clinic Quality in Surgery Department. According to a news report, Cima said when they investigated cases of a sponge being left behind in a Mayo procedure; they found that 70 percent of the time the count was recorded as right. Apparently they had hit what he calls the "human performance barrier." "We just couldn’t get any better without something new," he added. Mayo added the Surgicount system at its hospital, and the system keeps track of who did the scanning and patient IDs. It records a master tag for each bundle of sponges as they are put into service and accounts for each used sponge before they are discarded, reducing the chance of leaving any behind. "It won’t let me double count a sponge," according to Mayo Surgical Nurse and safety team member Jack Clark. "The machine never gets tired, never gets distracted and it’s there to reinforce our counting techniques," he said.
Caprice Greenberg, M.D. and Atul Gawande, M.D., of Brigham and Women’s Hospital in Boston published their “The Frequency and Significance of Discrepancies in the Surgical Count” study in the Annals of Surgery (News Brief On Study). In their investigation of 148 incidents of retained sponges and tools/devices left in patients, the authors uncovered a total of 29 discrepancies involving sponges, which equated to 45 percent. The majority of discrepancies denoted a misplaced tool/device (59 percent) as opposed to a miscount (3 percent) or error in documentation (38 percent). When an tool/device was misplaced, each unique search took an average of 13 minutes to resolve the missing item. The authors concluded that 1 in 8 such surgical cases involves a discrepancy in the count, and that the majority of such problem or discrepancies detect unaccounted-for sponges and other device/tools.
The Surgicount system has now been implemented at several Veteran’s Administration Hospitals, as well as a number of other privately operated hospitals, according to Surgicount Medical’s website.
The point for medical patient safety and prevention of medical malpractice is this: hospitals and clincs doing surgeries should be adopting any and all simple steps and remedies to reduce easily preventable “never events,” or the American system of tort law will impose monetary liability on a careless hospital and its staff, its that simple. Under our system of civil justice, the injured patient (or the family of the patient suffering a wrongful death) does not extract vengeance with an eye for an eye from the hospital—we have long since adopted a system of compensation to victims who must prove-in a court of law—that a hospital/surgeon/nursing staff was careless or negligent in order to recover anything as compensation. Medical malpractice cases involving surgical sponges/towels left inside a patient’s body usually seem preventable on their face, but this available technology is one more reason hospital liability in these type cases will be overwhelming.
About the Editors: Shapiro, Cooper, Lewis & Appleton personal injury law firm (VA-NC law offices ) edits the injury law blogs Virginia Beach Injuryboard, Norfolk Injuryboard, as well as the Northeast North Carolina Injuryboard as a pro bono service to consumers. Lawyers licensed in: VA, NC, SC, WV, DC, KY, who handle car, truck, railroad, and medical negligence cases and more.