Sponges, towels, medical instruments and other objects mistakenly left inside patients after surgery have caused 16 deaths since 2005, the Joint Commission
reported in a new sentinel alert warning hospitals and surgery centers to address the problem.
The Joint Commission said hospitals and ambulatory-care centers must improve their counting procedures and other safeguards to reduce the number of objects left inside patients after a wound closure. The costs from the errors—including unreimbursed Medicare payments, plus legal and surgery fees—could range from $166,000 to more than $200,000 per incident. About 95% of the 772 cases of unintended retention of foreign objects, or URFO, logged between 2005 and 2012 resulted in extended hospitals stays or additional care, according to the alert. Those statistics came from volunteer reporting, and officials said the actual number of incidents are probably higher.
The biggest drivers of these errors, the Joint Commission said, are lack of policies; failure to comply with existing policies; poor communication between doctors and staff; and poor staff education. Hospitals also need to better develop a culture where staff members don't feel intimidated when speaking out about mistakes.
“Leaving a foreign object behind after surgery is a well-known problem, but one that can be prevented,” said Dr. Ana Pujols McKee, executive vice president and chief medical officer for the Oak Brook, Ill.-based Joint Commission. “It's critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns.”
Other factors that bring higher risks included overweight patients, urgent and emergent procedures, unexpected changes during a procedure, multiple procedures and staff turnover during a surgery.
The Joint Commission urged hospitals to better educate staff about policies and to develop clear policies to keep track of and count surgical objects that could be left in patients. Counting policies should be revisited, including inspection of instruments for breakage before and after use to reduce the possibility of fragments left inside a patient. Intra-operative radiographs should be used if a count is incorrect.
Communication could be bolstered with team briefings and debriefings that stress the dangers of leaving objects behind. Surgeons should also verbally verify counting results.
“Before the procedure or as part of the time out, the surgeon could remind the team that the patient or procedure is at risk for an URFO,” the report used as an example. “During the procedure, a white board could be used to display the count and to help foster team awareness and shared responsibility; at the end of the procedure, team members can raise or be asked about any concerns related to the procedure or the patient's recovery.”
The commission also encouraged the use of technologies such as bar-coding, radio-opaque material and radio frequency tags or radio frequency identification systems to help count and detect items.
Technology, while potentially an effective tool, must complement hospitals' efforts to establish standardized procedures for counting objects for all surgical departments, said Dr. Verna Gibbs, a professor of clinical surgery at University of California in San Francisco whose work is cited in the Joint Commission alert.
Hospitals must take a larger role in changing the culture rather than relying on individual clinicians to make changes, said Gibbs, director of No Thing Left Behind, a group formed to raise awareness of the problem.
“If you have 20 nurses and 30 surgeons in an operating room, you would get 30 different practices on how they count,” she said. Follow Ashok Selvam on Twitter: @MH_aselvam