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Ensure equipment isn’t left inside patient or face headlines, litigation
Study estimates 1,500 pieces left inside patients annually
It’s not an urban legend or an Internet rumor. A Canadian woman really did walk through a metal detector at an airport and trigger the alarm, which led to the discovery that a 33 cm surgical retractor had been left in her abdomen after a procedure. The woman had been complaining of chronic stomach pain since her surgery, but physicians had been unable to identify the cause.
And if you think that report is bad, consider this news: One U.S. hospital had three incidences of retained instruments and sponges in a one-year period, sources say.
The outpatient setting is particularly prone to such situations because there is "unreasonable pressure" to turn over cases rapidly and move patients along as quickly as possible, says Ramona Conner, RN, MSN, perioperative nursing specialist at the Center for Nursing Practice at the Association of periOperative Registered Nurses (AORN) in Denver.
"Sometimes, the safety of the patient is overlooked," Conner says.
The problem of leaving instruments inside patients is widespread, according to a recent study published in the New England Journal of Medicine (NEJM).1 The study, which is the largest and reportedly the most reliable on such mistakes, reported on 800,000 surgeries in Massachusetts from 1985 to 2001. Researchers found that 61 pieces of surgical equipment remained inside 54 patients after surgery. Most of the objects were sponges, but the items left inside patients include metal clamps and electrodes. In two cases, 11-inch retractors were left inside patients. In another operation, four sponges were left inside a patient.
The lost objects usually were lodged around the abdomen or hips, but sometimes they were left in the chest, vagina, or other cavities. They often caused tears, obstructions, or infections. One patient died of complications. Most patients needed additional surgery to remove the objects.
Based on their findings, researchers estimate that 1,500 pieces of equipment are left inside patients annually in the United States. However, at least one expert thinks that this estimate may be low. Sidney Wolfe, MD, health research director of the public-interest lobby group Public Citizen, points out that providers are not required to report such mistakes to public agencies. Other sources predict the number may be low because the research didn’t include cases settled out of court or cases that did not become lawsuits.
Retained objects can cause serious medical problems, including perforation of the bowel, sepsis, and death. The NEJM researchers found that claims ending in litigation resulted in an average of $52,581 in costs for compensation and legal defense expenses.
How is this happening?
One of the factors contributing to the problem is human error, particularly when providers are in a hurry, sources say.
"It happens because no one’s infallible, and it happens because as humans, we become rushed and take shortcuts," Conner says.
Emergencies can be particularly challenging. For example, in the outpatient setting, a tonsil bleeder may have to return to the OR so the tonsil bed can be packed.
Emergencies often require extra staff and equipment, says Lori Bartholomew, director of research at Physician Insurers Association of America in Rockville, MD. There can be many medical specialists working on the patient, which makes organization very difficult, Bartholomew points out.
One-third of the cases the journal authors studied involved unexpected changes in procedure, including those with unanticipated findings of a perforated diverticulitis, ectopic pregnancy, duodenal mass or other new diagnoses, technical complications including bladder laceration requiring repair, and intraoperative respiratory failure.
More than half of the cases studied involved a change in nursing staff during procedure. Same-Day Surgery sources point out that even in outpatient surgery, it is not unusual to switch staff, especially on longer cases, so communication and documentation are essential.
Interestingly, the NEJM researchers found that a rise of one point in body mass index raises the chances of equipment being left inside by 10%.
Obese patients simply provide more room and more fat in which to lose objects, researchers say.
Sometimes, obese patients have sponges left deep in their pelvis or high under the diaphragm, says Richert Quinn, MD, physician risk manager at COPIC Insurance Co. in Denver.
The researchers suggest that extraordinary steps, such as taking postoperative X-rays even though the count seems to be correct, be taken with obese patients.
Such steps should be considered carefully as more bariatric surgeries shift to the outpatient setting, Conner suggests. Another area of concern for outpatient providers is eye procedures, because those cases use small needles, which are easy to overlook, she warns.
Sometimes, providers take steps that put them at risk for retained equipment, says Waldene Drake, RN, MBA, vice president of risk management at Cooperative of American Physicians — Mutual Protection Trust in Los Angeles.
For example, additional sponges may be brought into the room, staff may use them to clean their glasses, and they end up in the patient’s abdomen, she says.
Or an extra piece of equipment or a tray may be brought into the room, "so when they’re cleaning up, they aren’t aware that an extra instrument should be accounted for," Drake adds.
If providers take the steps necessary to result in fewer errors, fewer injuries, and fewer poor outcomes, such as following counting policies, then fewer malpractice suits will follow, Quinn points out.
"Anything we can do to raise the quality bar and improve patient safety is good for consumers and good for us," he says.
1. Gawande AA, Studdert DM, Oray EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003; 348:229-235.
For more information, contact:
• Lori Bartholomew, Director of Research, Physician Insurers Association of America, 2275 Research Blvd., Suite 250, Rockville, MD 20850. Telephone: (301) 947-9000. Fax: (301) 947-9090. E-mail: email@example.com.
• Ramona Conner, RN, MSN, Perioperative Nursing Specialist, Center for Nursing Practice, Association of periOperative Registered Nurses, Denver. Telephone: (800) 755-2676. Fax: (303) 338-5165. E-mail: firstname.lastname@example.org.
• Waldene Drake, RN, MBA, Vice President of Risk Management, Cooperative of American Physicians — Mutual Protection Trust, 333 S. Hope, Eighth Floor, Los Angeles, CA 90071. Telephone: (800) 252-7706. E-mail: Wdrake@cap-mpt.com.
• Richert Quinn, MD, Physician Risk Manager, COPIC Insurance Co., 7351 Lowry Blvd., Denver, CO 80230. Telephone: (720) 858-6131. E-mail: email@example.com.
The Association of periOperative Registered Nurses (AORN) recently developed Safety Net, a voluntary reporting system to capture data about close calls and near misses in the surgical arena. Information about surgical close calls initially will be collected only via the Internet at www.patientsafetyfirst.org/safetynet.htm. For more information, contact AORN Patient Safety First Hotline at (866) 285-5209.