tag:blogger.com,1999:blog-4968787219619380438.post7449379912500046300..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: "Thousands" of errors made by surgeonsSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger44125tag:blogger.com,1999:blog-4968787219619380438.post-981430356875384342015-12-29T18:41:35.366-05:002015-12-29T18:41:35.366-05:00When I was operating, I never argued with anyone w...When I was operating, I never argued with anyone who said the count was wrong. If we couldn't reconcile it, I ordered an x-ray. It's not worth arguing about. Most sponges or instruments left in patients occur when counts are erroneously thought to be correct. Those are the bad ones. I agree the surgeons should have an idea of how many lap pads are in the abdomen, but I can't count the instruments and sponges myself. Therefore, I refuse to be held responsible for it. Just do your own job and do it right. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-69119010860196026702015-12-28T19:06:21.169-05:002015-12-28T19:06:21.169-05:00I was an OR nurse at Johns Hopkins for 15 years an...I was an OR nurse at Johns Hopkins for 15 years and the count was my responsibility. I agree that the surgeons must pay attention to how many laps or sponges they put in the patient and they must stop closing and listen to the circulator or scrub nurse when they say the count is wrong. If my count is wrong twice, I order an X-ray with or without the agreement of the surgeon. This is my license at risk also. Who is to say that a third count which comes out correct is the right or wrong one again? I am responsible for the count and my patient as much as the surgeon is. Every time I have had to call x-ray for an incorrect count, it was usually preceded by the surgeon's saying, "Well it's not in the wound." Surprise.LHBnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-8660255925998195632015-12-28T18:01:50.033-05:002015-12-28T18:01:50.033-05:00One additional thought, I disagree in your thought...One additional thought, I disagree in your thought that the Surgeon is not responsible. It is a team, we should work together, but the "Captain of the Ship" is still the prevalent feeling in many Surgeons. The Kentucky case I agree 100%, but if the Surgeon is present, he/she is part of the team and is/should be the team leader. We all have our responsibilities and if you as the Surgeon wants to not be the team leader than the RN has to then step up. Quite honestly I have had to do that and feel it is not my responsibility, I hate it. And one thing else....there are always lazy incompetent people, regardless of the job title. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-60373034220302415542015-12-28T17:53:26.930-05:002015-12-28T17:53:26.930-05:00It is a team effort, but as the RN, it is my room,...It is a team effort, but as the RN, it is my room, my count and I take responsibility if it is wrong. I will not allow my tech to argue with me on what we count or how many times we count. That includes the Surgeon....we may do more than I want, but never less. I am constantly recounting and interacting with my tech throughout the case and we do "mini counts during the surgery especially if it is a chest/abd case. And yes I have had to deal with a few arrogant Surgeons who truly think the letters at the end of their name says GOD, not MD.....but as the RN my responsibility is totally to the patient. In 99% of the time surgeons are as concerned as much as I am and do everything possible to ensure a correct count, but there are that minority. And I have had to document once, "Count incorrect, surgeon notified and refused X-Ray. X-Ray ordered per hopital policy, foreign body detected, surgeon notified." And yeah, I guess I am kind of arrogant too.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-33326491686898345542015-11-14T10:12:26.102-05:002015-11-14T10:12:26.102-05:00Good point. My only concern is that I'm not su...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.<br /><br />Here's a brief blog post by a friend of mine about hoe sponges and lap pads look on x-ray. http://regionstraumapro.com/post/133134018739Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-8406179042443829652015-11-13T13:29:14.282-05:002015-11-13T13:29:14.282-05:00The 'problem' here isn't defined in oc...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-26132571782642846482014-01-22T18:15:39.757-05:002014-01-22T18:15:39.757-05:00Thanks for commenting. I agree that a needle found...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.<br /><br />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.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-80808112510077620572014-01-22T15:32:25.364-05:002014-01-22T15:32:25.364-05:00I've thoroughly enjoyed this thread! I am an ...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!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-72447732975806348872013-07-14T21:58:27.033-04:002013-07-14T21:58:27.033-04:00Emm, that's a funny story. I have not heard of...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.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32321279531434544322013-07-14T14:59:49.184-04:002013-07-14T14:59:49.184-04:00I don't want to fall in the trap of weighing i...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.<br /><br />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: <br /><br />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.<br /><br />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?Emm-Nullhttps://www.blogger.com/profile/03989735815413273036noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-19904705990554128052013-07-03T12:54:24.986-04:002013-07-03T12:54:24.986-04:00Anon, thank you for your comments.
It depends on...Anon, thank you for your comments. <br /><br />It depends on your point of view. You can't imagine a lazy nurse but you have no trouble seeing an arrogant surgeon.<br /><br />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.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-80106236795392596002013-07-03T12:32:10.765-04:002013-07-03T12:32:10.765-04:00Holy cow - I have not seen so much mud slinging si...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!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87478794730034873322013-07-01T08:56:31.095-04:002013-07-01T08:56:31.095-04:00Interesting case. I'm sure there are many more...Interesting case. I'm sure there are many more people walking around with things left inside who do not ever experience problems.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-29284121548455108812013-07-01T08:44:48.939-04:002013-07-01T08:44:48.939-04:00I will forever remember the case where a prominent...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. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-48267387592264593612013-06-30T12:31:37.994-04:002013-06-30T12:31:37.994-04:00SurgeonFromPakistan, thanks for commenting and sup...SurgeonFromPakistan, thanks for commenting and supporting my position. <br /><br />Nurses want to be treated as equals. They don't want to take "orders" from doctors any longer.<br /><br />Well then, step up and take responsibility for doing your job--that is, counting the sponges and instruments.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-75476685898953397852013-06-30T12:10:07.061-04:002013-06-30T12:10:07.061-04:00Agree with you. It's not about shifting blame,...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.<br />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.<br />Smaller sponges are another story altogether. They are more easily missed.<br />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.<br />Just my take on the issue.SurgeonFromPakistannoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-10852142791807128242013-03-05T08:39:02.552-05:002013-03-05T08:39:02.552-05:00Thank you for commenting.
"What's your ...Thank you for commenting. <br /><br />"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.<br /><br />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.<br /><br />At one time, surgeons were considered responsible for the actions of the anesthesiologist too. Thankfully, those days have passed.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-3620450559199389642013-03-05T00:15:35.075-05:002013-03-05T00:15:35.075-05:00I'm sorry, but I must agree with Ben. You, ... 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!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-89038245651436620472013-02-13T07:09:57.484-05:002013-02-13T07:09:57.484-05:00Amy, thanks for supporting my position. I agree wi...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.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-11727549672000263512013-02-13T02:30:10.871-05:002013-02-13T02:30:10.871-05:00The circulating nurse is there to make sure the co...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. Amynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-76533874508973997002013-02-08T22:07:32.181-05:002013-02-08T22:07:32.181-05:00You make a good point. No matter whose fault it is...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. <br /><br />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. <br /><br />I think these things occur because they are so rare that staff gets careless. I wish I knew how to keep that from happening.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87856489649964113052013-02-08T16:21:49.228-05:002013-02-08T16:21:49.228-05:00I believe you, but as a patient, what concerns me ...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?<br /><br />(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?)Matthewnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-53102474704039301232013-01-05T12:53:32.805-05:002013-01-05T12:53:32.805-05:00Jeffrey, thanks for commenting. I like your blog &...Jeffrey, thanks for commenting. I like your blog "Buckeye Surgeon" (http://ohiosurgery.blogspot.com/).<br /><br />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.<br /><br />"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.<br /><br />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."<br /><br />If the final exploration looking for things left in was so reliable, we wouldn't need to have the nurses count anything, would we?<br /><br />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.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-52932238217644537322013-01-05T09:36:51.960-05:002013-01-05T09:36:51.960-05:00"Listen to me. Surgeons are not the cause of ..."Listen to me. Surgeons are not the cause of sponges being left in patients. I’ll explain."<br /><br />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".<br /><br />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. <br /><br />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 Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-25658652177016857782013-01-04T10:01:47.990-05:002013-01-04T10:01:47.990-05:00Thanks for commenting. That surgeon must have been...Thanks for commenting. That surgeon must have been fun to work with.<br /><br />I was occasionally a cranky bastard, but only when people failed to perform adequately. I never interfered with a count.<br /><br />The good news is I think "Good Ole Boy" hospitals are disappearing. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.com