Earlier this year, a report in The New England Journal of Medicine prompted stories in the general press ringing with alarm.
Two physicians at a hospital in Japan recounted treatment of a 42-year-woman who complained of lower abdominal bloating, which she said had been ongoing for three years. The medical exam found evidence of nontender masses on her iliac fossae, and subsequent radiographs showed hyperdense lesions.
The patient underwent a laparotomy. Two masses were removed. When the masses were cut open, the surgeons found gauze inside.
The patient had undergone cesarean sections on two separate occasions several years earlier, leading to speculation that the sponges were left behind during one of those procedures. Given the timetable laid out in the report, the sponges existed inside her for at least three years before symptoms arose.
The case represents a nightmare scenario for patients and surgeons, but it’s also a shockingly common occurrence. Although termed a never event — those situations the Centers for Medicare and Medicaid Services (CMS) insist should never happen to a patient — the most dependable estimate puts the number of surgical instruments left inside of patients annually at 6,000. Of those, roughly 70 percent are surgical sponges.
There are multiple approaches to solving the problem of retained surgical bodies, all part of the continuing movement to codify cultures of safety in healthcare facilities. Checklists and rigorous counts are often emphasized in surgical protocols.
Sponges are trickier to inventory than other items in the OR. For one thing, there are simply a lot of them. A major surgery can utilize about 100 sponges.
In those quantities, even the most determined efforts at keeping count can be thwarted.
Atul Gawande, MD, MPH, surgeon and author of influential book The Checklist Manifesto, once used a familiar task from a game room to illustrate the difficulty.
“And if you’ve ever counted a deck of cards and tried to confirm whether you have 52 cards, you know that you will miscount a known number of times,” Gawande told CNN in a discussion of the dangers of retained surgical bodies.
In addition to the threat to patient safety, retained surgical bodies can be costly to hospitals. Facilities that made the mistake can be hit with considerable fines levied by regulatory agencies and also face malpractice lawsuits that result in jury awards running to six figures or more.
The checklist approach that Gawande helped popularize is a useful countermeasure, but healthcare professionals are increasingly looking to technology to provide additional protections. As barcoding and other automated processes are introduced as part of the supply chain management side of hospital operations, it only makes sense to incorporate related tracking technology right into the OR space.
High-tech measures can have a daunting price tag, but some protections — for patients and practitioners — are investments against outcomes that are far costlier.