In the October issue of The Journal of American College of Surgeons, researchers at the University of North Carolina at Chapel Hill reviewed 2,285 surgical cases where sponges were tracked using a new system called RF Assure Detection.
A tiny radio-frequency tag (the size of a grain of rice) was attached to each sponge. When the operation is complete, a detector alerts the surgical team if any sponges remain inside the patient before they are closed up. In the UNC study, the system has helped recover 23 “forgotten” sponges from approximately 3,000 patients over an 11-month span. The detection system, created by a thoracic surgeon at Weill Cornell Medical Center in New York, adds about a $10 cost to the procedure, which is roughly the cost of a single suture used in surgery. “It’s a small price to pay to enhance patient safety,” said Dr. Leo R. Brancazio, medical director of labor and delivery at Duke University Hospital in North Carolina, which adopted the RF Assure Detection system 18 months ago, after a sponge was left inside a patient during a Caesarian delivery. “It’s one step that takes 12 seconds at the end of a procedure.”
There are about 4,000 cases reported every year of surgical items being left inside patients, mostly gauzy sponges. Doctors use the sponges to control bleeding during the procedures. The longer the surgery, the more sponges used.
A woman in Texas recently filed a lawsuit against her doctor for failing to remove a surgical sponge following her 2004 abdominal surgery. It wasn’t until 2010 (six years later) when she experienced pelvic and abdominal problems and sought help. It was then that doctors found the lower quadrant of her abdomen contained a lap sponge marker, which required surgical removal.
Surgical errors are serious and can have fatal results. When a foreign object, such as a surgical sponge, is left inside your body, infections and internal bleeding can occur, which might not be identified until it is too late. Many tools are mistakenly left inside patients: clamps, scalpels, occasionally even scissors. But sponges make up about two-thirds of all retained items.
In 2005, while working an overnight shift as a nurse in Kentucky, this victim felt excruciating pain in her abdomen, causing vomiting. The following day, a CT scan discovered a surgical sponge left behind by a surgeon who performed her hysterectomy four years earlier.
Following immediate surgery to remove the sponge, “what they found was horrific,” the victim said. “It had adhered to the bladder and the stomach area, and to the walls of my abdominal cavity.”
The lingering sponge caused an infection, which required a large part of her intestines to be removed. She sued the hospital where the original surgery (hysterectomy) was performed and in 2009 she won $2.5 million in damages.
The award was appealed and although the sponge is gone, its’ effects have destroyed her way of life. She suffers from anxiety and depression. At age 59, the victim is unable to work due to the severe bowel issues. She says that most days, she finds it difficult just to leave her home. Her award was $861,178 including $61,178 in medical expenses.
Of the 4,000 annual cases of “retained surgical items” in the U.S., no two cases are the same. The core of the problem, experts point out, is that the surgical teams use old-fashioned methods when it comes to tracking the sponges and other surgical items. In most operating rooms, a nurse keeps a manual count of the sponges used during the procedure. In a fast-paced operating room, it is understandable that mishaps can occur. This is why new technology and sponge-counting methods are being implemented in order to help save lives.
Another tracking system relies on bar code technology. Each sponge receives a bar code, which is scanned before use and then scanned again, after it is retrieved. Dr. Berto Lopez, an ob-gyn and chief of the safety committee at West Palm Hospital in West Palm Beach, Florida said that nationwide, “less than 1 percent of hospitals employ it…In my heart, I think it comes down to hospitals not wanting to spend the 10 bucks.”
Dr. Lopez became an advocate for electronic tracking after he was sued in 2009 for leaving a sponge inside a patient. This error occurred, he said, after two nurses assured him that all sponges had been accounted for. He now refuses to operate in any hospital that does not use electronic tracking. Dr. Lopez said that even though radio-frequency tracking is relatively cheap, many hospitals do not want the added expense.
Dr. Gibbs, of NoThing Left Behind, explained that some hospitals now use inexpensive “counter bags” that resemble shoe storage bags that hang from closet doors. Each sponge has its own compartment. If a compartment is empty at the end of an operation, a nurse can see that a sponge is missing. Then, Dr. Gibbs said, an electronic tracking system can help find the missing sponge.
When it comes to patient safety, you can never be too careful. If currently, there is new technology available at a reasonable cost, and it has proven to be effective, why wouldn’t it be mandatory in every operating room throughout the U.S.? Wouldn’t you feel safer knowing the chances of you leaving the hospital with a sponge or a scalpel in your abdomen, are minimal due to the new tracking devices?
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