Monday, December 24, 2012

"Thousands" of errors made by surgeons

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.


James said...

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.

artiger said...

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.

Angie said...

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.

Skeptical Scalpel said...

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.

Anonymous said...

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 is a team work in the end.

Karen Sibert MD said...

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.

Anonymous said...

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

artiger said...

Aspiring Surgeon, let us know how you feel when you've eliminated "Aspiring" from your title.

det-res said...

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.

Skeptical Scalpel said...

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.

Ben said...

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.

Skeptical Scalpel said...

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.

Ben said...

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.

Skeptical Scalpel said...

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.

Anonymous said...

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!

Skeptical Scalpel said...

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.

Anonymous said...

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.

Skeptical Scalpel said...

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.

Anonymous said...

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...

Skeptical Scalpel said...

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.

Jeffrey Parks MD said...

"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.

Skeptical Scalpel said...

Jeffrey, thanks for commenting. I like your blog "Buckeye Surgeon" (

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.

Matthew said...

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?)

Skeptical Scalpel said...

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.

Amy said...

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.

Skeptical Scalpel said...

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.

Anonymous said...

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!

Skeptical Scalpel said...

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.

SurgeonFromPakistan said...

Agree with you. It's not about shifting blame, as some seem to surmise from your post. It's more about respecting another professional enough to let her do her job so you can do yours.
I have had instances, as a junior surgeon, where, particularly in cases of trauma or full blown peritonitis, even the lap sponge gets so soaked up with blood/bowel contents that despite a thorough sweep, you can miss it. A middle-of-operation count usually takes care of that for us.
Smaller sponges are another story altogether. They are more easily missed.
So as a rule, I never use free gauze sponges in cavity operations. Maybe attached to a long sponge holding forcep or even a hemostat but never free.
Just my take on the issue.

Skeptical Scalpel said...

SurgeonFromPakistan, thanks for commenting and supporting my position.

Nurses want to be treated as equals. They don't want to take "orders" from doctors any longer.

Well then, step up and take responsibility for doing your job--that is, counting the sponges and instruments.

Anonymous said...

I will forever remember the case where a prominent thoracic surgeon performed a successful pulmonary bullectomy on a patient with COPD. She lived an additional ten years and was tragically killed in an accident. Postmortem examination, presumably done for legal reasons, revealed a large surgical towel in her chest, left behind following her successful surgery. She suffered no ill effects, had many chest x-rays which did not document the presence of the towel and probably lived much longer than she would have if the surgery had not been performed. The surgeon was sued, but I believe the defense prevailed as no harm could showed as a result.

Skeptical Scalpel said...

Interesting case. I'm sure there are many more people walking around with things left inside who do not ever experience problems.

Anonymous said...

Holy cow - I have not seen so much mud slinging since the last presidential election! I am a 40 year veteran OR nurse who is no stranger to incorrect counts, fortunately none of which resulted in a retained surgical item. I agree that the count is the responsibility of the nurse and scrub tech but I'm not so sure that I agree that the surgeon has no culpability. Yes, the nurse is responsible for keeping an accurate count; yes, it is the responsibility of both nurse and tech to keep track of what's in use and what's temporarily kept in, but the surgeon has the responsibility to facilitate the count. In our facility, the surgeon is required to do a "hard stop" at the final count, prior to skin closure. After the count is declared correct, skin closure proceeds. There are so many variables as to why a correct count could result in a retained surgical item: case acuity, surgeon denial, communication, human error, activity level in the room at the tiome of count, but I would be hard pressed to actually come up with the excuse of a lazy nurse! I remember challenging a doc about an incorrect count on a TRAM flap. He didn't believe he could have left a lap pad in and refused to stop closing as the staff tried to locate the missing item. Our policy requires an xray, read by a radiiologist, prior to leaving the OR room, if there is an incorrect count and it was done. On looking at the xray, the plastic surgeon rather haughtily declared that there was nothing in the breast. I looked at the patient's breast and convinced the surgeon to retake the xray because the breast profile looked "lumpy", not the usual quality of his work. Guess what - the lap pad showed up on the second xray! So, essentially, it is a team effort to insure correct counts; admittedly the OR nurse's most important function is to make sure there are no retained surgical items, but the surgeon must also take accountability and not perceive his or herself as above it all when challenged. BTW, if you had a discrepancy in needle count in my facility, the count would be documented as incorrect!

Skeptical Scalpel said...

Anon, thank you for your comments.

It depends on your point of view. You can't imagine a lazy nurse but you have no trouble seeing an arrogant surgeon.

I agree it is a team effort, and I have never over-ridden an incorrect count. But at some point, the surgeon has to trust that the nurse and scrub tech have counted everything correctly. This is particularly true when the count is deemed "correct." The vast majority of objects left in patients have occurred after "correct" counts, that were in fact not correct.

Emm-Null said...

I don't want to fall in the trap of weighing in on something that a bunch of accomplished professionals have already discussed when I'm only just about to start medical school, so I want to share something anecdotal from before I even knew I wanted to go to med school that helps explain how difficult it can be to keep and accurate count of these things.

When I was had my wisdom teeth out, they used two balls of gauze (admittedly different than a lap pad or surgical sponge, but very similar) to control the bleeding in the back of my mouth. When I got home, I had to take both of them out and replace them with fresh gauze. I pulled the first one out from the left side, but the one on the right side of my mouth didn't come out when I pulled on it. I didn't want to break anything back open and start bleeding again, so for several minutes I carefully held on to it and worked it around inside my mouth to try and gently get it free. After several minutes, my brother walks into the room and starts laughing hysterically at me. After a few seconds I figured out why:

I'd been so intent on removing that second object on my mouth (because I *knew* there were two in there) that I hadn't noticed the dried blood had actually stuck them together and I'd gotten them both on the first pull. Because of all the drugs, I couldn't feel that I had been sitting in the kitchen pulling on my own tongue for almost five minutes straight. When stuff that was pristine white becomes soaked through with blood, it looks a lot different than when it started.

I also had one question about making this easier. In researching this, I've seen proposals for lap pads with unique RFID chips to help keep the count accurate, but it seems to me that if you're already having issues where lap pads are packed too many or too few to the package, that will mess up your count anyway. Has anyone ever tried adding a dye to them that turns them some obnoxious color when they're soaked with blood so they're easier to identify?

Skeptical Scalpel said...

Emm, that's a funny story. I have not heard of trying to impregnate the pads with a dye. It might work. Of course, there would be issues with the dye and toxicity, allergies and who knows what else.

Anonymous said...

I've thoroughly enjoyed this thread! I am an OR RN and I definately can imagine a lazy OR nurse, but also arrogant doctors. There are so many factors affecting a count. For me personally I hold myself fully accountable. That said I believe everyone coming in contact with that lap, needle, instrument has some responsibility. And yes, most retained items have been in a correct count. I have had close calls from instances where I was out of the room getting another instrument set and the anesthesiologist gave sutures to the field. Most of our anes. do not add things to the board when they give something. Luckily our case was not in some crazy hectic mode and the scrub told me what was given/received, but that right there sets me up for an incorrect count for which I am not fully responsible. If I was not told and it ended up missing I would have had a correct count at the end with the full knowledge and comfort that it was an accurate count...NOT. So many mitigating factors. I don't think that the surgeon should be counting laps, but if he puts them in he should be aware of how many, and not be angry when being told he's short a lap and it probably is still inside the belly! And techs shouldn't argue when a nurse is trying to do a preop or post op count about what should be counted. If it is requested to be counted then it should be done. I don't know how many times I have had to argue with one tech in particular about counting on certain cases. I always bring up an article I read when I first started out about a retained sponge in a person's lip! Now no one can imagine that, so it is a perfect example of why you should count even in the small incision cases. He usually shuts up at that point. In a perfect world in the OR people wouldn't argue, treat people with respect and they would do their jobs! But life isn't perfect which is why we ALL should remain vigilant for the patient. And as you said about a fool sabatoging counts...well you know what they say about a fool..."a fool and his money, they are soon parted!" and as a side note, just curious on what your thoughts are for found items on the floor....ex. you are missing a suture needle and you find it on the floor. Is your count still correct or would you want an x-ray? I had a surgeon who argued, (with good points), that anything "found" on the floor does not make a correct count as you cannot be entirely sure that it was not left in the room from a previous case. While we clean our rooms fairly well, and move the OR bed, I can definately see something being left in the room. I have relieved on a vascular case and ended up with the scrub flinging a needle out of the needle boat by accident trying to disengage the needle into the boat. These needles are small and sometimes found but a few times have not been. Now I know if we found a vascular needle in a case we knew we never opened any it might make a difference, but if we were in the same case an old needle could be mistaken for the missing needle. Would you still want an x-ray? And then there is the argument that the vascular needles are so small that there is no point in x-raying they will not show up. What's yourpoint of view? Thanks!

Skeptical Scalpel said...

Thanks for commenting. I agree that a needle found on the floor could have been from a previous case, although it doesn't say much about the staff's safety procedures or thoroughness of the clean up.

Any metallic object, no matter how small, will show up on an x-ray. The problem is that the portable x-ray machines used in most ORs do not have the power to penetrate obese patients. Small details can be hard to see. I once saw a large lap pad missed on a portable film.

Anonymous said...

The 'problem' here isn't defined in occupational terms. It's human: sponge counting in an OR environment has been shown to be 99.3% accurate. Sounds great, but the 0.7% catches up to us over enough volume and produces a missing or retained sponge. If you like statistics, 99.3% is about 4 Sigma performance --which is an airline you definitely wouldn't fly. Further up the performance scale, "6 Sigma" is 99.99997% error-free. And that kind of performance is more in the realm of the mentioned radiofrequency-based solutions.

Skeptical Scalpel said...

Good point. My only concern is that I'm not sure the radiofrequency sponges have been studied enough. I know they function well in controlled environments, but operator error could be a problem in real world usage.

Here's a brief blog post by a friend of mine about hoe sponges and lap pads look on x-ray.

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