About 30 times a year, a hospital in Washington state leaves a sponge or surgical instrument inside one of its patients. The accident known as a “retained foreign object” is one of the state’s most commonly reported medical mistakes.
Washington hospital patients in 2012 wound up with sponges, retractors, plastic tubing, wire fragments, catheter tips and endoscope tips, among other objects, left inside them. Hospitals take great pains to avoid these potentially harmful mistakes, but they have been mostly unable to achieve the goal of No Thing Left Behind.
At the University of Washington Medical Center, a surgical team is prepping a 49-year-old man for a hernia repair. Before they put him under or cut into his abdomen, they go through a long checklist of preparations.
The checklist is designed to minimize the chance of harming the patient that the hospital is trying to help.
A big part of the prep-work is a careful count of every piece of metal, cloth or plastic that might end up inside the patient during surgery. Circulating nurse Bonnie Saling and surgical technician Maurice Lybarger inventory a long list of retractors, blades and other instruments.
“Sponges?” Saling asks.
While the patient’s heart monitor beeps out a slow rhythm, Lybarger counts off a pile of 10 gauze sponges. Then five more. Then another pile of 10.
Even a relatively simple surgery can involve dozens of sponges.
After the patient has been stitched up, Saling and Lybarger will repeat their count to make sure nothing’s gone missing inside.
Checklists and counts have been widely adopted by hospitals in recent years. But medical mistakes -- including objects left in patients -- remain a leading cause of death and injury nationwide.
Hospitals are required to report all their serious mishaps, including any retained objects, to the Washington State Department of Health.
The numbers fluctuate year to year. Five years in a row (2007-2011), the University of Washington Medical Center had the state’s worst record of leaving things inside its patients, averaging about four per year, according to health department data. Then last year, UW had a perfect record: Nobody came out of surgery with anything unwanted left inside them.
Hospitals with MultiCare in south Puget Sound and Swedish in Seattle reported leaving the most objects in their patients in 2012: a total of six times at MultiCare facilities (Tacoma General, Good Samaritan and Auburn Medical Center) and five times at Swedish First Hill.
“It’s really an uncommon event,” says chief medical officer John Vassall of Swedish. A large hospital will perform thousands of surgeries each year. Swedish, the state’s largest hospital, does more than 30,000 annually. “We’ve been working diligently on a daily basis to reduce harm to our patients,” Vassall says.
Yet Vassall and other health care experts say such egregious errors shouldn’t just be uncommon: They should never happen. That’s why they’re called “never events.”
Vassall says the system of pausing to count sponges and instruments isn't as straightforward as it might appear.
“It works, but it’s not perfect,” he says. “When you're counting the sponges at the beginning, the sponges are nice and clean and white and sterile.”
Used sponges, on the other hand, are crumpled up, soaked in blood and possibly stuffed out of sight inside the surgical opening. “They blend in with all the tissues,” Vassall says. “It’s a lot harder to find them and to count them.”
Hospitals have tried to make it easier for surgical teams to get accurate counts of their used, bloody sponges.
“We have these sort of hanging racks where you actually put the sponges in a visual display,” says UW chest surgeon Tom Varghese. “The surgical team can actually look and say, yes, those are the actual sponges that were used.”
While few hospitals have adopted it, there’s also a high-tech fix for leaving a sponge in a patient.
“It’s incredibly rare, if new technology’s used,” says Dr. Lester Reed, the vice president in charge of patient safety at MultiCare. The Tacoma-based hospital chain uses electronically enhanced sponges: Inside each sponge is a radio-frequency tag about the size of a grain of rice. If a sponge is hiding inside a patient, waving an electronic wand over the patient will set off a bleating alarm.
According to its Bellevue-based manufacturer, RF Surgical Systems, the sponge-tracking system costs about $10 per surgery. The main problem: It’s a lot easier to embed electronics inside a sponge than in a retractor made of steel.
UW Medical Center and Swedish officials say they’re considering using electronically trackable sponges, but they’ve focused on improving their hospitals’ safety cultures and teamwork first.
“I believe sometimes mistakes are made if you just think, ‘Hey, if I introduce this technology, that’ll solve the problem,’” says Tom Varghese with UW.
Hospital officials say there’s something more important than any technology in making hospitals safer: communication.
“Communication really rests, we now know, at the heart of almost all medical errors, in one way or another,” Reed says.
Hospitals are hierarchies, and in an operating room, the surgeon is often the alpha dog. It can be intimidating for others to speak up.
“These aren’t physicians who are screaming at patients or at nurses,” Reed says. “It’s a subtlety — the subtlety of arrogance that might be present.”
He says Tacoma General and the other MultiCare hospitals have been working for the past five years to improve the way doctors and nurses interact.
After a retractor turned up inside a Tacoma General surgery patient last year, an internal review pointed to poor communication between a male surgeon and an unidentified nurse.
“She or he didn’t quite feel comfortable enough to say, ‘I don’t think something’s right here,’” Reed says.
The lost retractor led the hospital to change its tool-counting procedures. The patient received an undisclosed settlement from MultiCare. The surgeon involved no longer works at Tacoma General.
Breaking The Ice
Back in the UW operating room, preparations for the hernia surgery continue.
Surgeon Patch Dellinger orders his seven coworkers to speak their minds.
“Anybody with questions? Concerns?” Dellinger asks. “Any questions, concerns, observations at any time during the procedure, you must speak up immediately. Otherwise, we’re ready to roll.”
The team takes a second safety pause. This time, they do something even simpler than counting sponges: They introduce themselves.
“I’m Patch, surgeon,” Dellinger starts off. The seven members of the team follow suit.
It’s not rocket science, but sometimes just knowing somebody’s name makes it easier to talk to them.
“Something as simple as that reduces a number of errors,” says John Vassall with Swedish. “In the past, it would be very difficult for a nurse or, say, an environmental services worker to stop a doctor and say, ‘I don’t think this is right.’ In many places, that’s still the case.”
Without fearless communication, Vassall says, “we can’t have a safe system.”
Masking Surgical Mistakes
When it comes to external communication about their mistakes, hospitals are often less interested in people speaking up.
“Patients often don’t know when something has gone wrong, and it’s not something that hospitals or doctors come forward and say,” says Bainbridge Island trial lawyer and nurse Carol Johnston.
Many hospitals say they embrace transparency as a tool for growing safer and helping consumers make informed choices. But when patients or their survivors settle medical negligence lawsuits with hospitals, the hospitals routinely seek confidentiality agreements — gag orders — to keep them from talking about their settlement or their problems with the hospital.
“I think they don’t want the embarrassment out in the public light, and they don’t want people to know about their fatality rates and about their injury rates,” says Tacoma trial lawyer Nathan Roberts.
“Most companies, when they settle lawsuits, have confidentiality agreements that go along with that,” Washington State Hospital Association spokeswoman Mary Kay Clunies-Ross says. “We’re no different.”