Found: 13-inch retractor was left inside a patient

Surgeons in Seattle accidentally left a 13-inch metal retractor inside a patient for a month, leading to a $97,000 settlement and a change in hospital procedures for counting instruments.

The hospital admitted that this was not the first time its surgeons lost large retractors inside patients.

The surgical team did not notice that the large retractor was still in the patient and did not notice that it was missing after the surgery. The patient complained of pain after the surgery, but his doctor kept telling him the pain was normal, even 30 days post-op. Finally, the man went to his own physician, who found the retractor on a CAT scan.

Eric Larson, MD, medical director at University of Washington Medical Center (UWMC), says the hospital accepts full responsibility for the error. Larson publicly apologized to the man and said the hospital has implemented procedures to reduce the likelihood of another such incident. The new procedures include counting retractors — something that previously was not done even though smaller instruments are counted routinely in operating rooms. The theory was that a 13-inch retractor would be noticed, so there was no need to count them.

"Our staff work diligently to count accurately and discover ways to improve our processes and aim for zero defects," Larson says. "Thus, we have dedicated additional resources to expedite a thorough review of all of our operating-room counting practices in order to re-engineer any related process or procedure that would further increase patient safety."

Four others since 1997

Larson says the hospital administration knows of four other "very similar errors" involving retained metal surgical instruments that have occurred at UWMC since 1997.

The issue came to light when 49-year-old Donald Church publicly revealed that he had settled his case for $97,000. He had undergone surgery in June 2000 to remove a tumor, his appendix, and part of his intestine. But when the hospital responded to Church’s announcement, other cases were revealed. The most recent case of a lost retractor occurred in September 2001, Larson says.

"The patient had a complex abdominal surgery at our hospital in September," Larson reports. "A malleable retractor used in closing the incision was mistakenly left in her body. We removed the object in October. We have accepted responsibility for this error and apologized to the patient. As in the case of Mr. Church, the woman has made a full recovery from her cancer surgery and is doing well."

Larson says that although there are little published data on the subject the staff at UWMC are confident that such errors are uncommon. At UWMC, they represent one in approximately 12,000 cases per year — or less than .01% of all cases performed at UWMC since 1997.