It seems like something out of a horrendous nightmare-the idea of a surgeon accidentally leaving surgical tools inside of your body. Even with modern counting methods and technologies used to keep track of tools, retained surgical items (RSI) are a unique surgical complication that still occurs, although rarely, to this day. According to an article by Loyola University Health System, published in 2007, about 1,500 patients in the United States annually have objects left inside of them post-surgery (“Surgical Objects Accidentally”). Bear in mind though that this number could be higher. In fact, many institutions choose to keep reports of such incidents confidential whenever possible or simply do not know yet about items that they have left behind. Scary stuff.
Geraldine Nicholson was a 56 year old woman who opted for surgical intervention as a form of cancer treatment. Ten weeks after her surgery, she began experiencing severe complications and returned to the hospital. Upon further inspection, medical professionals discovered that a surgical sponge had been left in her abdomen by mistake. Mrs. Nicholson, a mother of three, ended up succumbing to her cancer and dying as a result of the complications related to the RSI (“Objects Left In”). In the medical field this sort of event is classified as a “never-event” because it should NEVER occur and is 100% preventable.
It is estimated that ⅔ of all objects left inside of the body are sponges because high numbers of them are often used and they become saturated with blood and other fluids, causing them to blend in (“Surgical Objects Accidentally”). Some other common objects seen in cases like this include, but are not limited to, needles, scalpels, tubing, clamps, and gloves (Bailey).
Although it is hard to believe, most patients with RSIs tend to heal normally and go back to their daily routines-at least for a while. In fact, many patients are asymptomatic for months or even years before they realize anything is wrong at all (Cima). RSIs have the potential to be life-threatening. Some symptoms can include bleeding, tissue damage, bowel blockages, infection, pain, confusion, and high fevers.
Even with the best of intentions human error can sneak into every facet of our lives-including operation rooms. There are a plethora of reasons as to why and how objects get left behind. Situations where this is most likely to occur include emergency operations, during unplanned changes during an operation, and on patients with a higher body mass index (Cima). Of course, poor team communication, inaccurate counting methods, and distractions all can play a role in it as well. Even though patients are the ones with the most to lose in instances involving RSIs, it is important to take into account the effect that such an event can have on the institution as a whole as well in relation to reputation loss and legal costs (Cima).
Okay, so here is the good news. Hospitals have been focusing on ways to properly prevent such “never-events.” Institutions have lengthy, multi-step processes for manually keeping track of surgical tools. On top of that, most hospitals have also implemented bar-coding technology to lessen the probability of human error. An example of this in action is with heat-stamped sponges. Each sponge has a unique bar-code that is scanned before and after use. If a sponge is unaccounted for, the machine will alert the team before the operation is completed. These reports are printed and checked over in addition to item counting (“Surgical Objects Accidentally”). Although this happens less frequently, there are still annual occurrences.
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Until Next Time
Bailey, Regina. “Objects Most Commonly Left Inside The Body After Surgery.” Thoughtco. 25 July, 2019. Accessed 22 February, 2021. thoughtco.com/objects-left-inside-body-after-surgery-4061352.
Cima, Robert R. “Undetected Foreign Objects.” Patient Safety Network. September, 2012. Accessed 22 February, 2021. psnet.ahrq/web-mm/undetected-forign-object.
“Objects Left in the Body After Surgery.” Public Citizen: Health Letter. April, 2012. Accessed 22 February, 2021. citizen.org/news/objects-left-in-the-body-after-surgery/.
“Surgical Objects Accidentally Left Inside About 1500 Patients in US Each Year.” ScienceDaily. 9 December, 2007. Accessed 22 February, 2021. sciencedaily.com/releases/2007/12/071208171847.htm….