Health Letter, April 2013
It is an event that should never happen to anyone. Ten weeks after Geraldine Nicholson underwent surgery for cancer, doctors discovered that a surgical sponge had been left in her abdomen. The discovery was the beginning of a yearlong hospital stay as Nicholson, a 56-year-old mother of three, struggled with infections and illness that prevented her from receiving follow-up chemotherapy and radiation treatment. Eventually, she succumbed to the cancer that the surgery had been intended to prevent.
Nicholson is one of a small but disturbing number of patients who die each year from infections, complications and other causes related to foreign objects left behind after surgery. Objects, often sponges, that are left behind during surgery can remain in a patient’s body for years without detection, adhering to organs and leading to pain, infection and other problems.
The most tragic thing about these deaths and injuries is that they are completely avoidable, so-called “never events” that could be prevented if all hospitals were to enact systematic measures to address them. Some hospitals are now working to take such steps. To help prevent this never event from happening to you, it is important to understand the safety protocols and consider the questions to ask before going in for a nonemergency (elective) procedure.
Scope of the problem
The estimated number of objects left behind after surgery (also called “retained objects”) varies each year, ranging anywhere from between 1 in every 1,000 surgeries to 1 in every 18,000 surgeries. However, hospitals vary widely in how many retained objects they report. Some hospitals may claim no retained objects for years, while others report one object left behind every three months.
The reports are even more difficult to interpret because retained objects can easily be missed, meaning that a hospital with poor systems for detecting the objects may not even notice that a mistake has been made until years later, when it causes devastating injury.
Nearly any object that enters the operating room, from small needles to large surgical tools, can be unintentionally left behind after surgery, but the most common retained object is a surgical sponge or similar absorbent pad. These small, soft items are easy to lose because they can be wadded up and become soaked in blood, blending in easily with nearby tissue. Dozens may be used during an extensive procedure, making it more difficult to keep track of each one.
Objects Left Behind After Childbirth
Surgery is not the only procedure in which objects can be left behind. Hospitals are only now beginning to acknowledge that sponges and dressings used to absorb excess blood during a vaginal delivery also can be left behind and cause infections and other problems.
The problem in such cases is often poor communication: The obstetrician who delivers the baby will place a sponge or dressing in the vagina to address bleeding, then give verbal instructions to a nurse to remove the item later. The information is not transmitted to other members of the nursing team, and the patient is eventually discharged from the hospital with the sponge or dressing retained. She may return to the hospital weeks later with a fever or foul discharge, indicating infection.
Unfortunately, many labor and delivery areas have not implemented routine sponge-counting practices similar to those now used in the surgical setting. Hospitals should actively work to change this by introducing such practices and working to improve communication after delivery.
In the meantime, new mothers and their partners or advocates can actively help prevent problems by speaking to their obstetrician after delivery and learning whether a sponge or dressing was used. They can then ask how and when the item should be removed and ensure that this information is appropriately communicated to the nursing staff.
Detecting and removing retained objects
One of the oldest, most widely used techniques to prevent retained objects is a simple count. Sponges and other items should be counted when they arrive at the operating room and then counted again multiple times throughout the procedure to ensure that all objects are all accounted for before any cavity is closed. Unfortunately, it is easy for this system to go wrong. The surgical team may forget to count, count incorrectly, or fail to communicate and work together to find the missing object when a count comes up short.
Routine screenings during or after an operation offer one option. Standard surgical sponges generally contain a small marker embedded in the fabric that will appear on an X-ray, making it possible to scan for these objects. In one study, researchers used routine X-ray scans during and after surgery to identify sponges retained inside patients. Nurses had failed to notice that the sponges were missing during the operation, either because they did not perform a sponge count or because the sponge count appeared to be correct. However, routine X-ray scanning has drawbacks, as it exposes patients to risky radiation, and quality images are difficult to obtain during surgery. Newer technologies rely on radio-frequency tags or computer identification chips that can be detected without using X-ray. These technologies, discussed below, may ultimately be safer for patients, although none have been on the market long enough to understand the true best approach.
There may be limited circumstances under which it is undesirable to remove the object. For example, very small needles rarely cause injury, so a small needle found inside the body after surgery may be best left in place.
Even if the risk of injury from an object is small, a surgeon should always inform the patient about the object rather than trying to conceal the mistake. A patient has the right to discuss the options and make an informed decision about removing the object, independent of whether a surgeon thinks the situation is serious.
Solving the problem takes teamwork
Many of the mistakes leading to retained objects are due to inattention, poor communication or lack of organized response on the part of the surgical team. For this reason, the most effective way for a hospital to reduce the number of these events is to change the culture of the operating and delivery rooms through comprehensive training, active learning and sustained follow-up.
The Association of periOperative Registered Nurses (AORN) and American College of Surgeons (ACS) have each developed best-practice guidelines to prevent leaving objects behind after surgery. NoThing Left Behind, a national education project, also has worked with hospitals since 2004 to develop and disseminate evidence-based best practices. Many of the steps recommended are common-sense, such as requiring two people to participate in each sponge count, physically separating sponges as they are counted out loud, and pausing to count objects and visually inspect the patient before closing any body cavity.
Other simple steps are less obvious. For example, NoThing Left Behind recommends placing used sponges in clear plastic receptacles rather than in disposal bins lined with red “biohazard” plastic or white plastic. This is because miscounts can occur when red plastic hides a bloody sponge or white plastic hides a white sponge. Although many hospitals use red “biohazard” bins to ultimately dispose of bloody sponges, a practice required by regulation, doctors may temporarily place sponges in a clear plastic receptacle until a final count is made.
A good program for preventing retained objects takes attention, time and energy to implement. It is thus important for a surgical institution to have some method of measuring the program’s success, investigating mistakes and providing feedback to members of the surgical team. Ideally, the hospital will have a system for reporting and investigating cases of retained objects as well as “near misses,” or cases in which an object is misplaced during the procedure but located and removed before the procedure is over. A hospital also should conduct routine internal audits, in which each nurse or technician is observed performing surgical counts, with lessons from the auditing shared at staff meetings.
Over the past decade, various device manufacturers have worked to design improved systems to lower the error rates from manual counting. One technique involves barcode technology that allows a nurse or technician to scan each sponge during the counting process, with a running count displayed on a screen. Another system relies on a small radio-frequency tag, roughly the size of a jelly bean, embedded in each sponge. A wand passed over the patient will trigger an audible signal and light upon encountering a tagged sponge. A third system relies on a small identification chip about the size of a dime, also embedded in each sponge. Other new systems are under development.
Although many of these new systems show promise, they are relatively young technologies still being refined based on feedback from experience. No single system has emerged as a clear winner for hospitals and patients.
Some of the new technologies also are expensive and may not provide large improvements over low-tech substitutes, such as installing standardized dry-erase boards in every operating room for recording sponge counts or using designated plastic sponge holders to allow for easier visual inspection after a count is complete. Moreover, no form of technology can substitute for good training, communication and teamwork on the part of the surgical team, and newer devices should not be relied upon as replacements for current best practices.
Questions for your surgeon
If you are considering having an elective surgical procedure, it is always a good idea to explore various options to identify a hospital and surgeon skilled at performing the procedure. When you sit down to talk with a surgeon or hospital staff, one of the things you should discuss is how the institution will ensure that sponges and other objects are not left behind after surgery.
Ask whether the hospital has had any retained objects or close calls in the past few years. Learn what steps are being taken to monitor for and prevent such events and to actively educate hospital staff. Keep in mind that a hospital that reports no objects left behind may simply have inadequate detecting and reporting practices. It generally takes several years of active, concerted effort by a large hospital to reduce the number of retained sponges to zero in a year.
Preventing objects left behind is a team effort, and any member of your surgical team should be ready to provide a detailed description of the practices he or she will use in the operating room to ensure that this never event will not happen to you.