UPI -01/15/03
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Surgical instruments left in patients during surgery often
are attributed to negligence by surgeons, but a study released
Wednesday concludes the major causes are unplanned, emergency
operations and obese patients.
"The problem is presumed by courts and also by the public
to be due to people not taking the proper care but we found
that these cases seem to occur despite people following proper
procedures," Atul Gawande, lead author and a surgeon
at Brigham and Women's Hospital, told United Press International.
The study is the first to examine systematically the causes
of items being left in patients.
Most hospitals have policies in place that require two separate
nurses to count sponges and instruments twice before and twice
after operations to ensure no items are left in the patient.
Gawande's team reviewed 54 cases and found that "in the
vast majority of cases" the counting procedure had been
followed.
Instead, the study, which appears in the Jan. 16 issue of
The New England Journal of Medicine, found items are more
likely to be left in patients if there is an emergency operation,
sudden, unexpected changes in procedure or the person is obese.
The 54 cases occurred between 1985 and 2001 in hospitals in
Massachusetts.
However, Sidney Wolfe, director of the health research division
of the consumer group Public Citizen and a physician himself,
said Gawande's data does indeed suggest negligence. Counts
of sponges and instruments were less likely to be performed
on patients with an item left inside than patients who underwent
operations and did not have items left inside, Wolfe pointed
out.
Indeed, the study notes counting of instruments and sponges
were performed in only 67 percent of patients who had an item
left in them compared to 79 percent of patients in which no
item was left. "Not counting instruments is negligence,"
Wolfe said. "They don't focus on that but it's there."
Emergency situations probably increase the risk of leaving
an item in a patient because the priority is to treat the
patient and developments are happening rapidly so it is understandable
how an item might get overlooked, Gawande said, noting that
a typical operation may use more than 200 sponges and 200-300
instruments.
"Obese patients are more likely to have these rare events
presumably because in larger people there's more room to lose
things and it's more difficult to notice when things are left
in the patient," Gawande said.
The majority of the cases, nearly 70 percent, involved a
sponge cloth pads about the size of a table napkin being left
in the body. In four of the cases, two to four sponges were
left. Clamps were the next most common item, followed by other
miscellaneous instruments, Gawande said.
In some cases, the items were discovered the same day of
the surgery and in others they were not detected for more
than 6 years, he said. In more than half of the cases, the
items were left in the abdomen. Other bodily cavities in which
items were left included vagina, spinal canal, face, brain
and extremities.
These situations are of concern because they can lead to
serious complications such as damage to major organs and even
death in rare instances, Gawande said. In most cases, patients
require renewed surgery to remove the item and they tend to
have infection rates 40 percent higher than patients who underwent
surgeries without this complication.
"It's a very vivid problem but it's a rare problem,"
Gawande stressed. "We don't want to suggest there's an
epidemic of this." On average, it occurs about once in
every 9,000-19,000 surgeries and about once per year at each
large hospital, he said.
Methods to correct the problem could include "using
X-rays more liberally after surgery (to detect forgotten instruments)
before the patient leaves the room even if the count (of sponges
and instruments) is correct," Gawande said.
Newer technologies also could help. Book stores now place
devices in books that will trigger an alarm if the book is
not paid for and it might be possible to adapt similar technologies
to surgical equipment, Gawande said. A hand-held scanner could
be passed over the patient following an operation and an alarm
could beep if it detects an instrument or sponge.
"The public emphasis has been to punish people (for
negligence), but our findings don't support this," Gawande
said.
However, Wolfe suggested increasing punishment of doctors
might be part of the solution.
Enacting systems to reduce medical errors and increasing
disciplinary actions against doctors who commit malpractice
could help curtail this problem, he said. Wolfe also noted
most state medical boards fail to discipline doctors convicted
of malpractice adequately and little has been done to adopt
strategies to lower medical errors as suggested by a 1999
Institute of Medicine report, which found medical errors account
for as many as 98,000 deaths each year in the United States.
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