Surgical safety alarm

The Joint Commission has issued a new sentinel alert about a long-standing patient-safety problem in surgery—objects mistakenly left inside patients.

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 need to better develop a culture where staff members don't feel intimidated when speaking out about mistakes. And 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.

“It's critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well as to ensure that there is open communication by all members of the surgical team about any concerns.” said Dr. Ana Pujols McKee, executive vice president and chief medical officer for the Oakbrook Terrace, Ill.-based Joint Commission.

Sponges, towels, medical instruments and other objects mistakenly left inside patients after surgery have caused 16 deaths since 2005, the Joint Commission reported in its alert warning hospitals and surgery centers to address the problem.

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 recorded between 2005 and 2012 resulted in extended hospital stays or additional care, according to the alert. Experts say the actual number of incidents is probably higher.

The Joint Commission urged hospitals 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. Intraoperative radiographs should be used if a count is incorrect.

Communication could be bolstered with team briefings that stress the dangers of leaving objects behind. Surgeons should also verbally verify counting results. The commission also encouraged using technologies such as bar-coding, radio-opaque material and radio frequency identification systems to help count and detect items.

Technology must be combined with hospitals' efforts to establish standardized procedures for counting objects for all surgical departments, said Dr. Verna Gibbs, a professor of clinical surgery at the University of California at 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, 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.

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