“Never Events” And New Technology

It’s classified as a “never event” (a medical mistake which should never occur) in the medical field, and rightly so. A surgical instrument or other “retained foreign object” is never to be left in a patient after surgery. This is a completely preventable surgical error.

Unfortunately, this error happens all too often. One retained foreign object is left in a patient in every 5,500 surgeries. It is estimated that between 4,500 to 6,000 retained foreign object “never events” occur each year.

Needles left behind account for 9% of objects. 3% of objects are instruments such as scalpels and forceps. 21% of objects left behind are varied and include objects such as scalpel tips, masks, and screws. The most common object left behind in patients after surgery is sponges. Sponges left behind account for 67% of objects. Sponges are used during surgery to soak up blood and other fluids.

Objects left in a body can take months or years to be noticed. These objects spread harmful bacteria or cause painful tumors to grow around the object left behind. These actions can have significant long-term consequences for patients. One out of every 100 cases of objects left in a body results in death.

Prevention Methods

All prevention methods use a counting method to confirm everything that went into the patient also came out of the patient.

Traditional Method

The traditional method that has been used to make sure that sponges or other surgical instruments are not left behind in a patient has been to count the number of instruments beforehand and do a second count afterward. Doctors rely on these counts to be sure that nothing is left behind. But these counts can be unreliable. A 2008 study done by Mount Sinai found this method effective only 77% of the time.

With the average surgery utilizing about 300 surgical instruments, and major surgeries using around 600, you can see how manual counts might miss something.

New Technology

There are new upcoming methods of tracking sponges that hospitals can implement, designed to cut down on the risk, discussed in a 2013 USA Today article. But fewer than 15% of hospitals use such sponge-tracking technology. These high-tech sponges are equipped with electronic tracking devices.

But these sponge-tracking technologies do make a difference as the Mayo Clinic and the Indiana University Health system (“IU”) learned.

After a sudden jump in lost sponge cases in 2006, IU looked into sponge-tracking technology. The method implemented was to use sponges equipped with a radio frequency tag. Before surgery is completed, a scan is run to detect any remaining sponges. Since the implementation of the tracking system, there have been no sponges left in patients for five years.

The Minnesota Mayo Clinic has had similar results. Prior to adopting the sponge-tracking technology, the clinic used post-op X-rays to detect any objects left behind. If a sponge was detected, the patient was subjected to a second surgery. Now, to avoid unnecessary radiation exposure, the clinic uses a system where each sponge is given a unique barcode and is scanned before and after it is used. The Mayo Clinic hasn’t had a lost sponge in 4 years.

These two success stories beg the question: why isn’t every hospital using such technology? In 2013, a survey was done by USA Today of the FDA approved three sponge-tracking systems and it showed that less than 600 of the 4,200 surgery-performing hospitals had purchased sponge-tracking systems.

“Never events” like retained foreign objects after surgery happen because of negligence and may be grounds for a medical malpractice claim. To learn more about retained foreign objects and the complications they can case, click here.