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Medical field works to reduce number of surgical mistakes

  • Tuesday, Dec 25 2012
  • Written by  Anna Gorman, Los Angeles Times
  • font size decrease font size increase font size

Larney Johnson, 21, was treated at California Hospital Medical Center for a gunshot to the kidney. Three years later, doctors discovered that his surgeons had left a sponge inside him.

The bullet that struck Larney Johnson while he was playing basketball with friends punctured his kidney before lodging in his spine and immediately paralyzing him.

Paramedics rushed him to California Hospital Medical Center in Los Angeles, where surgeons repaired his kidney. But three years later, he said, doctors made a startling discovery: a surgical sponge had been left behind.

Johnson had to undergo a second operation to remove the sponge before spending six weeks in bed recovering.

"They are supposed to count every this and every that," said Johnson, 21. "Obviously someone didn't do the job."

Surgical errors have attracted widespread attention over the past several years, leading to new laws and policies. In 2007, California started requiring hospitals to report certain errors and fining them if the mistakes killed or seriously injured patients. The next year, Medicare stopped paying hospitals for the costs associated with certain errors. In 2011, Medicaid announced that it also would stop paying to fix certain preventable mistakes.

Nevertheless, about 2,000 patients nationwide have surgical material inadvertently left behind each year during operations. The errors have occurred during all types of procedures, including knee replacements, caesarean sections and gallbladder surgeries. The most common item left behind is a surgical sponge, but doctors have also left needles, gauze and other instruments inside patients.

A recent study by Johns Hopkins University School of Medicine researchers estimated that surgeons leave sponges or other items inside patients about 39 times a week. The researchers analyzed medical malpractice judgments and out-of-court settlements on preventable hospital errors between 1990 and 2010 and identified about 4,860 malpractice payments connected to surgical items left behind. Only a fraction of the cases result in malpractice judgments.

In California alone, hospitals have reported such incidents more than 850 times over the last five years, according to the state's Department of Public Health. Of those, nearly 70 resulted in penalties against the hospitals because of the danger posed to the patient. Last week, the department issued fines to four hospitals for leaving surgical items inside patients. One involved a sponge used during a heart bypass surgery, even though the physician declared at the end of the operation that all the sponges used in the operation were accounted for. Typically, surgical teams count sponges and instruments before and after operations.

Experts say it's very rare for surgeons to mistakenly leave items inside patients given how many operations are performed each day in the U.S.

The problem occurs because hospitals lack effective practices to prevent the errors, said Verna Gibbs, a surgeon at UC San Francisco Medical Center and director of NoThing Left Behind, a surgical safety program.

"You can't just go to the individual nurses, or the individual doctors," she said. "You have to address the practices. Unless the hospitals change the practices of both, we will continue to have retained surgical items."

About 80% of the time there is a sponge retained, Gibbs said, the team had declared that the count was correct. People can make errors while counting, so hospitals need to instead focus on creating a way for them to always know that the sponges are accounted for, she said. One way is by making sure that every sponge used in surgery goes into a plastic holder after the operation. If the nurses or surgeons see an empty pocket, then they know one is missing.

New technologies can help surgical teams get it right. For example, surgeons can use sponges with a sort of bar code that has to be scanned at the beginning and end of surgery. Or they can wave a wand over the patient to detect sponges with radio frequency identification tags.

Gibbs also urges surgeons and nurses to work together to minimize errors.

Even with the new technologies and teamwork, humans are still going to make mistakes, said David Perrott, senior vice president and chief medical officer of the California Hospital Assn. Hospitals around the state are working with Gibbs and others to try to change the culture at hospitals and minimize the chance for those errors to occur, he said.

"We take this seriously," he said. "We have seen significant improvements … but we need to do better."

The state Department of Public Health is also continuing to look at the issue, recently commissioning a study by UC Davis on preventing such mistakes. In addition, the department is proposing new regulations to allow fines for surgical errors even when they haven't caused serious harm to the patients.

Patients may not realize the problem for weeks, months or even years. Doctors usually discover a sponge when it causes an infection, or when a mass develops around it.

In Johnson's case, following the 2006 shooting and emergency operation, he had pain and recurring bladder infections. His urologist ordered a scan and discovered the sponge.

Johnson had the second operation at Marina del Rey Hospital. Johnson said he was frustrated by what happened but also relieved it wasn't something even more severe than a sponge. He has a new scar on his side but has not had any long-term repercussions from the retained sponge, he said.

The family sued the hospital and accepted a settlement but could not talk about the details because of a confidentiality agreement. Johnson said he never received an apology from the surgeon or the hospital.

The hospital released a statement saying that officials took the case "very seriously" and conducted a thorough investigation. Hospital officials also instituted a "team approach" to counting surgical sponges and instruments both before and after each procedure. "There has not been an event like this since," the statement read.

Johnson's mother, Sheila, said the experience was like something from a medical television drama, not something that she would have ever expected to happen to her son. Regardless of who is to blame, there needs to be more accountability so errors like this don't occur again, she said.

"You lose your faith in the medical system," she said. "It's not like you can just take a tag off of a garment. You have to be cut again."

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