Over the last few days, stories about “thousands of errors
made by surgeons” have received a lot of media and Internet attention. All of
this was the result of a paper
from Johns Hopkins that says surgeons leave an object in 40 patients per week,
perform wrong site surgery on 20 patients per week and perform the wrong
operation altogether in 20 patients per week.
The paper reported 9,744 such errors in a review of the
National Practitioner Data Bank over the 20 years from 1990 to 2010. I’d love
to tell you how they extrapolated from 9,744, which over 20 years averages 9.4
such errors per week, to 80 per week, but the paper is not accessible to those who
do not subscribe to the journal Surgery.
I agree with those who say these are “never” events that are
totally preventable and should never happen.
But I want to set the record straight.
Listen to me. Surgeons are not the cause of sponges being
left in patients. I’ll explain.
A surgeon is about to perform an appendectomy. Before she
arrives in the operating room, the circulating nurse and the scrub technician
will have assembled all of the equipment needed to do the case. They also will
have carefully counted all of the instruments, needles and sponges.
[The “sponges” are not like the ones you use to clean your sink. They
are 4 X 4 inch gauze pads or larger cloths called lap (short for “laparotomy”)
pads.]
The surgeon has nothing to do with the counting either
before or at the end of the surgery. As the wound is being closed, the nurse
and tech perform another count to verify that all sponges etc. are accounted
for. A third count is done after the skin is closed. There are checklists for
this.
When I protested on Twitter that surgeons were being blamed
for the errors involving objects left in patients, many people responded that
if I was in charge, I should verify that the counts were correct. I replied that
I could either do the surgery or do the counting, but not both. You see, as the
case progresses, I might have asked for more equipment or a suture that was not
on hand at the start of the case. The staff must add these things to the total
count. If a new package of lap pads was opened, they must be counted before
they can be used. Would you want your surgeon to look away from your bleeding
wound to count the sponges?
Others brought up the alleged “fact” that the surgeon is the
“captain of the ship.” That principle, which was established in Pennsylvania
law in 1949, has been abandoned by most states. Here is a quote from a textbook
on nursing malpractice:
“The viability of this doctrine is dubious, at best, in
today’s health care system. Each perioperative health care provider is
considered a professional with responsibility and hence accountability for
specified tasks and individual actions.”
Many more such references can be found.
By the way, I wanted to see how the prestigious Johns
Hopkins Hospital, which is where the authors of the paper work, is dealing with
medical errors. However, when I searched the Leapfrog
patient safety website, this is what I found for Johns Hopkins Hospital.
Attempts to solve the problem of retained objects with
technology such as barcoding sponges or placing radio frequency tags on them
have not caught on. And those measures would not be able to help with instruments
or needles.
Yes, no object should ever be left in a patient. But at
least get the headlines straight. If nurses and techs do their jobs, surgeons cannot
leave things in patients.
28 comments:
Nicely put. Even from a non-surgical point of view I completely agree. Altough I'm afraid your statement will not get much attention... after all, what media would like to blame the cute joung nurse or technician? As with many things, you can not win an emotional debate with a rational argument.
I know you were attempting to educate the public, but you cannot win in such a setting. We all appreciate you taking one for the team though.
I agree with you. I'm a registered nurse who works in the OR in Eastern Canada and consider the onus to be on the scrub and circulating nurses/technicians when it comes to counting instruments, sponges, etc. In my experience the surgeon is always aware of the count when placing each lap pad inside the patient but it's certainly not his/her focus (nor should it be).
As far as I'm concerned, as an RN working a case in any OR, the accountability for counting is mine.
Thanks for commenting. It's good to know that at least a few people agree with me. I particularly appreciate Angie's taking ownership of the issue.
I agree 100% a surgeon should not be distracted to count guazes or instruments...even though the surgeon & / assistant are usually aware of how many are in & keep notice to take them out & ask the nurse to recount before closure...it is a team work in the end.
Want to hear something really silly? At my hospital, I'm required to sign a piece of paper at the end of every case verifying that I agree that the counts were correct. I'm the anesthesiologist, for heaven's sake. I have about as much to do with the counts as the cashier in the cafeteria does.
We protested when this ludicrous form first appeared, but of course to no avail. Hospital administrations rarely listen to reason. I usually sign the form while the patient is in preop.
You've persuasively established that surgeons are not responsible for errors with the count, but the count is not the only issue here. Someone, often the surgeon, must place the sponge in the body then neglect to take it out in advance of the count even occurring. Surely the surgeon bears some of the responsibility here? There's a lot going on and no one is perfect, but I hope that you endeavor to limit the incidence of this error in your own operations.
Aspiring Surgeon
Aspiring Surgeon, let us know how you feel when you've eliminated "Aspiring" from your title.
I am a first year surgery resident. I completely see what you are saying. Yet I respectfully disagree with you. It may be the job of nurses and techs to count lap pads and sponges, but we as surgeons use them on our patients and if I put one in to stop bleeding or irrigate or hold bowel, then it is my responsibility to make sure I take it out. I don't care if that goes into the garbage and the counts are wrong, but I would take full responsibility in leaving behind a foreign body, that I put there in the first place. It would really help in reminding me if others in the room did their job, for sure.
Thanks for all the comments.
I agree that surgeons should try to remember that they placed a sponge inside a patient and where it was placed. Before closing, I always took a very good look around to make sure I had not left something.
I disagree that surgeons should try to verify or accept full responsibility for the count. It is particularly difficult for the surgeon to keep track of sponges, needles and instruments in emergency cases or cases in which complications such as hemorrhage have taken place.
Karen, the policy that the anesthesiologist must sign off on the count is absurd. It simply adds another defendant to the lawsuit.
You are the surgeon. You put the sponge in there. You should take it out. It's appalling that you're attempting to place the blame for surgeons' lapses in memory on virtually everyone else in the operating room.
So what you are saying is that along with my performing a complex operation for sometimes 4 or 5 hours, you would like me to remember where I put every one of maybe more than 100 sponges or lap pads, 50 or 60 instruments and 50 suture needles. Not only that, you'd like me to stop to count the sponges or lap pads, which come in packages of 5 or 10, every time they are opened.
If that is what the public wants, it is very unrealistic and would result in every operation taking twice as long as it does now.
Read the comment by Angie above.
You are the surgeon. You put the sponge in there. You should take it out.
Are you eventually going to want to have the ancillary staff check that you actually removed an appendix or a spleen so that you don't have to think about that either?
The counts are merely a backup to you. If something were to be retained inside your patient, both systems failed.
Would you then go to the bedside of a patient with a raging infection and a retained sponge and say, "Unfortunately, John, the circulating nurse, and Jane, the scrub nurse, didn't do their jobs properly. They are very sorry this happened."?
No. The patient would say, "Who was operating? Where were you during all of this?"
You would instead (I hope) say, "I am your surgeon. I am responsible for everything that goes on in my operating room. The buck stops with me." (I would also hope that you don't have 100 sponges 50 instruments and 50 needles inside the patient at the same time.)
Some surgeons I've worked with clip a hemostat to their gown for each item they put into the patient. When the item comes out, the hemostat comes off. If there are items still inside the patient, there will be remaining hemostats. Some also log the counts in real time publicly on the operating room's whiteboard. I'm sure you're familiar with these measures. Do you know why they do this? Because, like you, they don't want to have to think about counts, and yet, apparently unlike you, they still remain personally accountable to the safety of their patients without relying on someone else or ducking blame when things go wrong.
Ben, you seem to have all the answers.
Almost always when an object is left inside a patient, the sponge and instrument counts are correct. One way that this can happen is that an incorrect initial count was done. In other words, there were 11 lap pads in a package instead of 10. Or there were 16 hemostats on the back table instead of 15.
Are you telling me that surgeons you work with count all the sponges and instruments with the nurse and tech before the case is started? I have never seen that done or even heard of it.
Unless the surgeon is participating actively in all the counts, there is no way for her to verify that the counts are correct at the end of a case.
It may be unfortunate, but we must rely on other people to do their jobs correctly. I can't operate and give general anesthesia too. Yet I assure you if a patient dies on the table from an anesthetic complication, I will be sued too.
Regarding "ducking blame," we couldn't do that if we tried.
I have worked wth surgeons who refuse to allow us to perform counts by ways such as deliberately kicking sponges under the OR table, hiding sponges, refusing to count before packing sponges. Correct counts are a Team effort/ Responsibility!
I agree completely. I never understood why some surgeons behave that way (or many other surgeon behaviors, for that matter).
Anyone who deliberately sabotages a count is a fool.
As a former RNFA, I agree that it is the primary responsibility of the OR nurse but ultimately it is a team liability and responsibility. We work together as a team to make sure all counts are correct as well as to make sure ureters, nerves, etc are not "nicked" during a procedure. This would be the "surgeon's" responsibility. We are a team and if you don't believe it ask any lawyer who would love to divide and conquer.
I agree surgery is a team sport. But we all have different roles and responsibilities.
I can't count the instruments and sponges. I rely on the nurses to do it and do it correctly.
I am an RN who spent most of my career in the PICU, but worked in the OR as a circulating nurse for 3 years while getting my MSN for the day shift hours. I have to say…You must be easy to get along with in the OR if you think the surgeon isn't responsible for retained items left after counts. The ONLY times I EVER had to call for an X-ray after closing was due to a jerk of a surgeon who was yelling at us through the count, and refused to let us finish prior to his final closure..He would be out the door, saying "There is NOTHING left inside" as the door hit his backside, and I would usually have to call him back in from the lounge or scrubbing for his next case. Now, I am not trying to imply that this was a regular occurrence, but in the little bit of time I spent in that OR, were it not for a great team, there could have been some serious consequences! And I worked in a "Good ole Boy" hospital. We weren't on your report.. I promise...
Thanks for commenting. That surgeon must have been fun to work with.
I was occasionally a cranky bastard, but only when people failed to perform adequately. I never interfered with a count.
The good news is I think "Good Ole Boy" hospitals are disappearing.
"Listen to me. Surgeons are not the cause of sponges being left in patients. I’ll explain."
Not the best way to phrase the issue; rather too definitive. Of course, it is the nurse's primary job to make sure sponge counts are correct. But the surgeon affects the process in subtle ways, especially when the "counts are off".
Some surgeons are sloppy. They shove lap pads haphazardly thoughtout the abdomen. Or they dont perform a final exploration. There is a role they we all play.
Personal accountability is always best policy. Attendings, if they are worth anything, dont stand up at M&M meetings and blame residents. They accept responsibility. Same deal here.
Jeffrey, thanks for commenting. I like your blog "Buckeye Surgeon" (http://ohiosurgery.blogspot.com/).
As a former long-time program director, I agree that residents should not be blamed . . . UNLESS they deserve it. For example, if a resident doesn't get out of bed to see a sick patient who then crashes, it is not my fault. It's the resident's fault.
"Some surgeons are sloppy. They shove lap pads haphazardly thoughtout the abdomen. Or they don't perform a final exploration." I also agree with that.
In most cases where retained objects occur, the counts are correct. Here's a hypothetical situation. The preop count is incorrect. There are 6 needles on the field but the nurses count 5. They are marked down as 5. I did my final sweep and didn't see it. The final two counts are said to be correct, but an extra needle is left in. Is that my fault? I say "No."
If the final exploration looking for things left in was so reliable, we wouldn't need to have the nurses count anything, would we?
PS: I know of a case in which a 4x4 was left in a breast biopsy wound and and another in which a 4X4 was left in a laparoscopic appendectomy wound. Both counts were correct.
I believe you, but as a patient, what concerns me is not WHO leaves something behind, but the fact that it happens at all. Taking into account the human factors (inaccurate counts, grumpy surgeons, lazy nurses, etc.), can you suggest any procedural or technological changes that could reduce or eliminate the possibility of this happening?
(Incidentally, the inside of my body must be much different than I picture it if it's possible for a 4x4 sponge to simply go unnoticed! Evidently it's not exactly a "plain sight" environment?)
You make a good point. No matter whose fault it is, it should never happen. It is not a plain sight environment. A 4x4 soaked with blood can easily be overlooked.
It's human error, plain and simple. Humans can defeat any system. A recent paper noted that even RFI chips in sponges did not completely prevent retained objects.
I think these things occur because they are so rare that staff gets careless. I wish I knew how to keep that from happening.
The circulating nurse is there to make sure the count is right, end of story, that's their job. If something is obstructing them from doing that job than they have to report it. I don't work in the OR but I've had instances where I've had to report physicians for basically being asses. As a nurse, patient safety is my number one priority, they teach that the first day of nursing school and it's our most important job. I don't work under the physician, they aren't my boss and I don't care if they don't like me. I'm always professional and courteous, I expect to be treated that way. If I came out of surgery and found out that I still had something inside me the person I would be upset with is the nurse. The same goes for the medical unit, if I have high K level and the doctor orders potassium I expect my nurse is not going to give it to me no matter what the doctor says until they are satisfied that my best interest and safety have been met. I do feel that hospitals have an obligation to require a hostile free work environment, hissy fits and temper tantrums are not necessary, the days of the tyrannical MD long gone.
Amy, thanks for supporting my position. I agree with everything you said including the parts about challenging an incorrect order and not tolerating temper tantrums.
I'm sorry, but I must agree with Ben. You, as the operating surgeon, have the responsibility of performing the procedure, and that includes the insertion AND / OR removal of foreign bodies. What's your take on the nurses/ technicians doing a correct count and find they are, indeed, missing a sponge post op? who do they turn and point the fingers to? I agree, nurses have duties to count before and after and often times during,, but YOU as the surgeon have a duty to not leave scalpels and needles inside of your patient. In the end, both parties have their responsibilities. Your position puts the blame 100% on your nurses, which is absolutely absurd. You're a doctor for God's sake, take responsibility too!
Thank you for commenting.
"What's your take on the nurses/ technicians doing a correct count and find they are, indeed, missing a sponge post op?" My take is, "We need to look for the missing sponge and we aren't leaving the room until we find it." It's happened to me and most surgeons many times.
If they aren't responsible and I am, then why have them count at all? I'll just do it myself and the surgery will take a lot longer.
At one time, surgeons were considered responsible for the actions of the anesthesiologist too. Thankfully, those days have passed.
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