So-called “retained surgical items,” including sponges and other surgical implements, being left behind during surgery are not necessarily a rare occurrence, according to a watchdog group.
The Joint Commission is asking hospitals nationwide to try and put an end to retained surgical items—also known as retained foreign objects—according to HealthDay News. “Leaving a foreign object after surgery is a well-known problem, but one that can be prevented,” Dr. Ana McKee, the Commission’s executive vice president and chief medical officer, said. The Commission sees this as a too-common problem that can be deadly or significantly damaging to patients minds and bodies, HealthDay News wrote.
The Commission indicates that more than 770 reports of retained foreign objects have been left in patients in the past seven years, resulting in 16 deaths; in most cases—95 percent, in fact—patient hospitalization was extended, according to HealthDay News. Typically retained foreign objects include sponges, towels, broken instrument pieces, parts of staplers and needles, and other sharp objects. McKee believes this is just part of a larger problem and that the actual number of cases is likely closer to 1,500-2,000 annually. Errors cost up to $200,000 per incident, according to the Commission.
“It is critical for organizations to develop and comply with policies and procedures to make sure all surgical items are identified and accounted for as well as to ensure there is open communication by all members of the surgical team about any concern,” McKee said, according to HealthDay News.
Some procedures and patients are likelier to be involved in retained foreign object situations, such as overweight patients, rushed or emergency procedures, patients undergoing multiple procedures, or staff turnovers during procedures, noted McKee.
The Commission recommends creating a meaningful and standardized counting procedure during surgeries, wound opening and closing procedures, team briefings and debriefings, creating an atmosphere in which team members feel free to discuss patient safety and concerns, and directions for when X-rays should be taken during surgery to locate stray items, to name a few, according to HealthDay News. “… problems with hierarchy and intimidation in the surgical team, failure in communication with physicians, failure of staff to communicate relevant patient information and inadequate or incomplete staff education,” are a part of the problem, the Commission indicates. When discrepancies are discovered, action must be taken and the incident recorded the Commission states. If any discrepancy is found between the objects counted and those remaining after the surgery, action must be taken and placed into the record, the Commission also points out, according to HealthDay News.
In 1999, the Institute of Medicine (IOM) published the famed “To Err Is Human” report, which indicated that as many as 98,000 people die annually due to hospital errors, according to a prior Philly.com article. In 2010, the Office of Inspector General for Health and Human Services indicated that some 180,000 Medicare patients died due, in part, to inappropriate hospital care. Meanwhile, a recent study, published in the Journal of Patient Safety, indicated that these numbers might be higher and involving 210,000-440,000 hospital patients annually suffering from a preventable harm that contributed to their death, according to Philly.com. If the figures are accurate, medical errors would be the third leading cause of death in the United States, just behind cancer and heart disease.
Research conducted last year indicated that surgeons make thousands of errors yearly in the U.S. The so-called “never events,” said The Wall Street Journal, are those mistakes that should not occur in medicine such as surgery on the wrong patient and leaving sponges inside patients’ bodies. Research suggests these serious medical errors occur with distressing regularity.