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Items Left In Patients Due To Emergencies
August 20, 2003

UPI -01/15/03 -
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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