A former Army mechanic from Ohio was recently awarded $275,000 in a medical malpractice case after a VA surgical team left two 11 x 14 inch towels in his body after removing a cancerous kidney.
The surgical oversight required 47-year-old Robert Sanner to undergo multiple follow-up exams, including a CT scan that revealed the error, then two additional surgeries ─ first to remove the towels and later to repair an incisional hernia caused by the second surgery, according to an account on Outpatientsurgery.net. Sanner missed a year of work due to the surgical errors and was left with a larger, thicker scar.
"Never-Events" More Common Than Expected
The National Quality Forum lists Sanner's situation as a "never-event" ─ a preventable medical mistake that should never happen. Others include operating on the wrong body part, as well as medical mistakes that lead to death or serious personal injury. But how common are these incidents?
Towels, sponges, needles and other surgical instruments are left inside one of every 1,000 to 1,500 people who undergo abdominal surgery, according to Findarticles.com. The problem is the traditional counting procedure, which is subject to human error.
Counting Objects is Useful but Flawed
While it is widely used, counting relies on total accuracy in a chaotic environment characterized by distraction, interruption and strict time constraints. To test its reliability, researchers at a major academic health care center in New York recently reviewed surgical incident reports from 2000 through 2004. The findings were:
•· Among 153,263 surgical procedures, there were 1,062 counting discrepancies ─ a rate of 0.69 percent
•· One in 7,000 surgeries involved a retained item ─ or one in 70 counting discrepancy cases
•· Final count discrepancies prevented 54 percent of retained items
•· Count discrepancies increased with the length of the surgery, the number of nursing teams and when surgery was performed on an emergency basis, or on a weekend or holiday
Counting plays an essential role in preventing retained objects from being left in surgical patients, but the practice has serious limitations. Additional safety measures, such as mandatory x-rays during long or emergency procedures and equipment screening systems that detect surgical objects are necessary to improve patient safety.