Surgical Objects Accidentally Left Inside 1500 Patients A Year

Did you have surgery this year? If so you may be the proud owner of a “surgical object” left inside you by your friendly doctor.

“When there is significant bleeding and a sponge is placed in a patient, it can sometimes look indistinguishable from the tissue around it,” said Dr. Steven DeJong, vice chair, department of surgery, Loyola University Chicago Stritch School of Medicine, Maywood, Ill. “Unintentional retained sponges and instruments is a devastating complication for patients and is a national problem affecting every hospital in the country that performs invasive and surgical procedures.”

Loyola has developed a new way to track sponges. It uses a bar code reader and a unique bar code on each sponge.

“When a sponge is removed from a patient, it is scanned back into the system. A surgical procedure cannot end until all sponges are accounted for. If a sponge is missing, the device will alert the surgical team what kind of sponge it is and the time it was scanned in.” This seems like an excellent idea, if you ask us.

Surgical Objects Accidentally Left Inside About 1,500 Patients In US Each Year [Science Daily via Digg]
(Photo:Getty)

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  1. stevemis says:

    I don’t see how this is novel. They’ve been counting the number of sponges used (expecting to have the same number at the end of the surgery) and leaving them inside people for a long time.

    Now, instead of counting them, they’ll scan them before leaving them inside you.

  2. protest says:

    barcodes? scanning? it’s a freakin sponge people! let’s try to keep the rediculous cost of medical care from ballooning further. here’s one: order neon yellow sponges so after they absorb blood they don’t look like tissue.

  3. kimsama says:

    @protest: This is a really good idea — is there some reason they aren’t doing this? Like, does bright dye present a possible allergen risk? Seriously, if not, good idea (when combined with counting, just to be safe).

    Another good idea would be making residents and such not work 36 hours in a row so they can, you know, remember shit like where they put sponges. Jesus, I wouldn’t let my mechanic fix my car on that little sleep. Why does medical care have to include a years-long period of hazing during which we are guinea pigs?

  4. louisb3 says:

    Unfortunately, the study doesn’t count how many surgical objects are intentionally left inside patients each year.

  5. cashmerewhore says:

    @kimsama:

    body tissues come in all different colors.

    except for in cadavers. then they’re pretty boring and grey.

  6. Aladdyn says:

    maybe a good place for an RFID chip??

  7. char says:

    My dad’s lost a couple of watches inside cows during surgery. Doesn’t seem to affect the cow at all, heh.

  8. whirlybird says:

    @kimsama: There are many reasons for not coloring sponges. First, their purpose is to absorb blood and other fluids. If you dye them, then they’ve used part of that absorption capacity to hold the dye. Given the horrible industrial nature of the chemicals used to create most bright dyes, you really don’t want to risk having your internal organs soaking up things like bug guts or coal tar. Finally, white == clean. It could be tricky to tell why that yellow sponge is so yellow.

  9. @Aladdyn: I’ve heard about them either wanting to do, or actually doing it with RFID chips. I’m guessing when the price drops down low enough, it might work. Also, I don’t know what kind of interference you might encounter in a surgical theatere. It would suck if they left one in you, and it corresponded with the RFID for a credit card, and you could get free gas or food with the forceps the Dr. left in you. Well, for the guy w/the credit card that is.

  10. Major-General says:

    Genetically engineered cotton that turns colors on contact with hemoglobin.

    But by the time ADM, Monsanto, and Johnson & Johnson got them to market, the only person using them would be Doctor McCoy when he get ornery and thinks Kirk needs to heal the old fashioned way.

  11. Cerb says:

    Counting usually works fine,1500 seems like a lot (and even 1 is too many) but considering the number of surgeries performed every year, it’s a pretty low number. There is no reason in and of itself that a barcode should be superior to the counting method.

  12. speedwell (propagandist and secular snarkist) says:

    I was a dumb 20-year-old college student when I had a kidney stone. They put a stent (a plastic tube) in between my kidney and bladder to facilitate the out-passage of the pieces after they did a lithotripsy (broke it up with focused sound waves). Problem is, I was poor and didn’t have any friends or family available to tell me that the doctor should have removed the damn thing after a while. The doctor never mentioned it; he probably meant to at the follow-up appointment I did not go to because I couldn’t pay for it.

    Anyway, 15 years later I’m half dead from a massive UTI, and the surgeon (a wise and compassionate fellow) got mad as a hornet’s nest when he heard what happened. Not at me. At the fact that he needed to remove what otherwise might have been a perfectly healthy and functional kidney. I’m OK but it was all so needless.

  13. cmac says:

    Not to say that leaving itrms inside people isn’t avoidable, but good consumers should notice that these medical catostrophe type reports are always reported in the number of people and not as a percentage. If this data was reported as a function of the number of surgeries performed in the US per year, this wouldn’t even be news.

  14. vongarr says:

    @speedwell:

    Wow, that sucks. Sorry to hear about that.

    I wonder how many unessacry surgeries doctors do every year because of stuff like this? Wouldn’t that raise the cost of health care? If follow ups were “free” or far cheaper, stuff like this wouldn’t happen. Dude would have an extra kidney, money would be saved, and the doctor would have been free to practice elsewhere.

  15. This is one of my FAVORITE specials on Discovery Health.

  16. Kavatar says:

    Did the study include Junior Mints?

  17. ooolam says:

    Wouldn’t it be nice if the sponge can be dissolved inside after certain period?! But I guess it will be too expensive and cannot absorb as much. Or maybe just attach a string to each sponge and tie all of them together.

  18. ColoradoShark says:

    @protest: I’m 99% sure what we normal folk thing of as sponges that we use to wash dishes is nothing like surgical sponges. I think they are a lot more what we think of as a piece of gauze.

  19. rbb says:

    @speedwell: Been there, done that, got the t-shirt twice. But, fortunately, both stents I got had a string attached. A very visible reminder…

  20. protest says:

    @ColoradoShark:

    yes i am aware of that. what is your point?

  21. BigNutty says:

    Lawsuit Alert! Hopefully they leave something in you that won’t kill you.

  22. AdmiralKit says:

    @protest: If you think the cost of medicine is so high because they print barcodes on sponges, you need to take a class in economics. Weigh the cost of printing a barcode to more effectively track the sponges versus the cost of a multimillion dollar malpractice suit when someone has to get cut open a month later to remove the sponge that is harboring a massive infection. This is being done to help reduce the cost of medicine. You pour enough blood on a sponge of any color and it’ll look like it could belong.

  23. @protest: Also, if someone was on the recieving end of say, a gall bladder surgery, neon yellow is a typical color to see!

  24. @ooolam: Dissolving sponges seems like a fantastic idea… I wonder what they’d have to make them out of?

  25. shanaynay says:

    Fat’s bright yellow. Fat is everywhere in the body, even in really skinny people. Maybe some other color, but still. This doesn’t happen because people are idiots and not looking for anything left in….

  26. Bay State Darren says:

    I can relate to this problem. Some idiot ortho surgeon left one of his damn screws in my shoulder. Can you believe he could be careless?

  27. mrestko says:

    Guys, the surgeons aren’t idiots or incompetent. As has been mentioned, the number of this type of complication as a percentage of all surgeries (ca. 50,000,000) is quite small. Obviously this isn’t something that you would want happening to you, but it most certainly is not a major issue. As ADMIRALKIT alluded, there is an economic concept known as diminishing returns, and this issue is a perfect example.

  28. cde says:

    How about one of those once-a-day-pill type containers. If there’s a sponge missing from a slot, you don’t stitch them up yet. Plus a string.

  29. vanilla-fro says:

    How about using one giant sponge? I mean like the size of a five year old, unless of course the surgery is on a five year old. For that you use one the size of a two year old, for a two year old you use one the size of a small dog, for a small dog you use on the size of a small cat, for a small cat…..

  30. prateeko says:

    Hey guys, just to chime in about the sponges. I’m not sure if you’ve ever seen the ones they use in the OR, but I assure you they are NOT at all like the ones you use at home. While my experience is limited to mostly neurosurgery (brain), I’m sure the situation is the same in other areas. When you need a sponge you’ve got enough blood coming out that suction is places almost permanently at the spot (it’s wedged with something). This is to be expected with many surgeries since you’ve got to access locations that have a lot of vascularization (i.e. lots of blood flow). After moments the sponges pretty much look like a part of the body. These sponges often have little pieces of strings with a tag on them (helps to find and remove them), so that is good in terms of not having them left behind.

    The count at the end of surgery is performed by the nurses, doctors and medical students aren’t involved in this (they’ve got too many surgeries to cram into a day anyway) so all it takes to realize you’re missing a sponge is a person miscounting. This system is clearly NOT ideal because you only realize this towards the end of surgery, but the usual work around is to do final counts as soon as you’re done with something. Most sponges, however, are probably not harmful since they’re (obviously) sterile to begin with and usually not an irritant (this can of course vary form person to person).

    Just a little input that may help to add some context…

  31. Cerb says:

    @vongarr: It’s all well and good to say followups should be free when you aren’t the one providing free labor.

  32. trrwilson says:

    True story:

    A girl I was dating had parents that worked in the medical field. Her dad worked as a physical therapy assistant, her mom was an LPN at a small hospital (which is now closed, so don’t worry). Well, one day, a patient whom both of them had seen before went in for a fairly routine surgery. She ended up dying of an infection not long after. When they did the autopsy, they found a sponge, and the person conducting the autopsy said it was the primary cause of infection and death.

    They were more amazed the sponge was missed, since, according to the mom, they counted them when they put them on the tray, when they take them from the tray, take them from the patient, and from the OR.

  33. AnnieGetYourFun says:

    Scanning seems as though it might be more efficient – although I guess you’d have to be careful not to throw one out and then spend hours searching for it while the patient was still… open.

  34. mamacat49 says:

    In most facilities, if you end up with a “wrong count” and it’s a sponge (or needle or something radio opaque) that’s missing, they call Radiology and a film is taken to look for it(while the patient is still asleep in the OR). Most sponges are embedded with little metal like threads that show up on an x-ray.

  35. Mindbleach says:

    I have an even lower-tech solution than x-ray visible threads in non-metal objects, and it’s preventative instead of corrective: use sponges with long, sterile/antibiotic ‘tails’ made of cotton. When the sponge is inserted, the doctor or nurse hangs the tail outside the patient, onto the table or near the instrument tray. When they go to close the patient up, either the long tail is obviously not tissue, blood-soaked or no, or it never made it far from the sponge, and it’s just a little more foreign material to remove.

  36. shanaynay says:

    @MindBleach: or a wee ball-chain like bank pens have? Put a bunch of little anchors under the lip of the op table and yo’ problem’s solved.

  37. mrestko says:

    @Mindbleach: Generally, long floppy tails are things to be avoided during sterile procedures. True, catheters and guide wires are long and floppy, but they’re generally the center of attention and less likely to flop somewhere they shouldn’t. Sponges are used continuously and liberally (at least in the surgeries I’ve watched) and they’d be much more difficult to manage if they had tails that needed hanging.

  38. tk427 says:

    It seems to me that someone will still be responsible for running the sponge under the scanner before handing it to the surgeon. Probably the same person who has always been responsible for keeping track of the sponge counts. The same person will now have the opportunity to forget to scan one sponge instead of forgetting to add it to the count the old fashioned way.

  39. Bay State Darren says:

    @Mindbleach: and shanaynay: No, the way to make that system work would be to attach the other end to the surgeon. Even if the current counting technique doesn’t work, the doc’s probably gonna notice if he’s physically unable to leave his patient [although that does sound a little kinky.] It’d be kinda like those janitors with the massive keyring tied to their belts. If this technology stops keys, well-known for their stealthiness and flight, from getting lost, it might just work for surgical doohickeys.

  40. the_wiggle says:

    @Cerb: how about pre-billing for the average# of follow-ups needed?

    @trrwilson: given the insane amount of overwork & under-rest, repeat in process miscounts like that don’t surprise me at all.

    perhaps since this is obviously a known issue, maybe all patients testing as anything less than perfect post op status should be immediately scanned or whathaveyou to avoid further injury & death

  41. polyeaster says:

    Preventative is not a word. Preventive is the word you were looking for…

  42. aegis1 says:

    OK, I’ll confess I’m a physician with a law degree. Because of this I see cases like this all the time. 1500 is probably a conservative estimate since many hospitals have inadequate or absent reporting systems. Some hospitals are frankly dishonest. Counting has never worked. The “tails, ” the RFID’s and the x-ray strips can be removed (and have been at sometime). This is an issue for everyone in the OR. No one person can prevent such occurences.

    You should be scared.