Wednesday, April 21, 2004

Scissors left in woman after surgery

A Sydney woman demanded an explanation Tuesday from a hospital where a pair of scissors were left in her abdomen after surgery and said she planned to sue.

Pat Skinner, 69, had part of her colon removed at Sydney's St. George Hospital in May 2001. But she said that she continued to suffer intense pain in her abdomen for months after the operation.

Eventually, she demanded doctors x-ray her abdomen. They did and discovered the 6.7-inch pair of scissors, which were removed in October 2002.

After wrong side or wrong-site surgery the most worrisome thing in the OR is leaving something behind you shouldn't have. While such cases as the one above and a few others get widespread attention, the situation is not an uncommon one:

About 80 times a year in the Philadelphia region, the tools of surgery - gauze, scalpels, needles, retractors and the like - are found left behind in patients.

This mistake occurs about once in every 3,800 surgeries in Southeastern Pennsylvania, an Inquirer analysis of hospital billing data has found.

When it does happen it's not cheap:

A northern New Jersey woman who developed a hernia and severe scarring from gauze left in for six months won a verdict of $5.8 million in 1996.

"It's not a question of whether you lose but how much you lose," said Peter Leone, a former Princeton Insurance Co. vice president now with the malpractice insurance start-up, NJ Pure. Even when there is little harm, he said, the cost to a hospital can be $50,000 to $150,000.....But the system is far from fool-proof. Chunliu Zhan, a physician and researcher for the federal Agency for Healthcare Research and Quality, found that this mistake occurs 2,700 times a year in the United States - a rate that closely tracks the Philadelphia region's.

Zhan found that a foreign body added four days to the average hospital stay and led to $36 million a year in added charges. More troubling, he said, about 57 people died from this mistake in 2000, the year he analyzed.

Leaving an instrument, sponge, or needle behind is almost indefensible as it falls under the legal principle of res ipsa loquitur which means, for the purposes of this discussion, that the mere presence of the retained foreign body (RFB) provides for negligence.

An excellent review, authored by everyone's favorite surgeon-writer, Atul Gawande, found here and summarized here and here .

The study found that in the instances when these types of errors do occur, they happen during emergency procedures, or in operations where there is a sudden change in plan. Additionally the research revealed that the higher a patient's weight the more statistically likely it is that an object will be inadvertently left behind.

"Often when you hear about these kinds of cases, people assume it is due to negligence," said Atul Gawande, MD, MPH, of BWH. "But we found that these errors usually occur despite teams following proper procedures. These errors tend to occur in unpredictable situations, such as emergency operations, that challenge standard protocols."......In emergency operations, retained object errors are nine times more likely to happen, the study showed. It was also determined that these errors were four times as likely to happen when the operation involved a change in procedure.

All hospitals follow procedures that mandate an inventory of all tools and sponges be taken before and after a procedure. But Gawande's research concluded that, while the careful counting of instruments is a valuable safety precaution, in over two-thirds of the cases objects were retained despite proper procedures being followed.

After statistical analysis of the records, Gawande estimated that at least 1500 errors of this type occur each year in the United States. However, given that over 28.4 million inpatient operations were performed in 1999 alone, such errors happen rarely, the study found. In fact, the current research showed that these type of errors occur in approximately 1 in every 9,000 to 19,000 surgeries that involve an open cavity.

Some advocate the routine use of x-rays to rule-out RFB, but critics of this approach opine that the post procedure counts are important as well and may not be taken seriously. Another problem with this approach is that some things used in the OR such as towels, penrose drains, vessel loops, and umbilical tape are not radio-opaque. On the other hand, towels and drains are not routinely counted during a case. The routine for counting varies from hospital to hospital. At big hospital the blades, sponges, and needles are counted at least twice (three times if a space within a space, such as the uterus, has been entered) during closure and the instruments are counted twice as well. At the Sisters of Blessed Confusion hospital most of the instruments are kept on a second back table and brought forward as they are needed. Those are the only ones that are counted.

This is one of those "but for the grace of God go I" situations. I don't personally count the parts and tools myself, I depend on the scrub techs and circulators to do so, and I know of no surgeon that counts his own stuff. This is a patient safety issue that has potential for improvement.
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