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Almost 800 patients have had surgical instruments left INSIDE them after hospital procedures causing 16 deaths since 2005, says new health care report
772 incidents of foreign objects left in patients between 2005 and 2012 Equipment like sponges, towels, needles, instruments, retractors and other small items and fragments of tools have been found in patients The report from The Joint Commission, a non-profit health care safety watchdog, shows it is due to human error and lack of protocols The watchdog calling for a stricter, more standardised counting system involving all members of the hospital team
By Daily Mail Reporter PUBLISHED: 20:16 GMT, 18 October 2013 | UPDATED: 20:16 GMT, 18 October 2013

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Nearly 800 people have had surgical instruments left inside them after having an invasive procedure at a hospital since 2005, according to a new report. The report from The Joint Commission, a non-profit health care safety watchdog, shows there were 772 incidents of foreign objects left in patients between 2005 and 2012, resulting in 16 deaths. Equipment like sponges, towels, needles, instruments, retractors and other small items and fragments of tools have been found in patients.

Horror operation: There were 772 incidents of foreign objects left in patients between 2005 and 2012, resulting in 16 deaths

Forgotten: Equipment like sponges, towels, needles, instruments, retractors and other small items and fragments of tools have been found in patients

The researchers found the most common causes of these incidents were due to human error and a lack of policies and procedures. The report notes that doctors traditionally rely on protocols like counting all of their tools or conducting cavity sweeps to look for equipment. About 80 per cent of retained sponges occur when the nurses and doctors think they've had a correct

count. In 95 per cent of the cases, patients had to stay longer in the hospital, according to CBS News. The most common sites these incidents occurred were operating rooms, labour and delivery rooms, ambulatory surgery centres or labs where invasive procedures such as catheters or colonoscopies take place.

Final count: Doctors traditionally rely on protocols like counting all of their tools or conducting 'cavity sweeps' to look for equipment

An incident was nine times more likely when an operation was performed in an emergency basis and four times more likely when the procedure changed unexpectedly. Sophia Savage, a nurse from Kentucky is one of those unlucky people to have experienced this first hand. She became violently ill in 2005, only to undergo a CT scan and find out a surgical sponge had been left in her abdomen during a hysterectomy four years earlier. What they found was horrific, Savage told the New York Times in 2012. It had adhered to the bladder and the stomach area, and to the walls of my abdominal cavity. She added, I never dreamed something like this would happen to me.

The Commission says she suffered severe health issues, anxiety, depression and disability. Savage sued the hospital where the surgery took place for $2.5 million, but the award was appealed.

Human error: About 80 per cent of retained sponges occur when the nurses and doctors think they've had a correct count

'Open communication': Ana Pujols-McKee, executive vice president and chief medical officer at The Joint Commission, who did the report. She says it is critical that hospitals comply with procedures

The watchdog is now calling for a stricter, more standardised counting system involving all members of the hospital team, including surgeons, nurses, techs, anesthesiologists, and radiologists. They recommend two people - a nurse and tech - count out all the equipment and have it verified by a surgeon. The counts should be performing them before the surgery begins, before the cavity is closed and at the time the procedure ends. A whiteboard can display the count, and the team should debrief to address any concerns about equipment or the procedure. Such a system was shown to reduce errors at one children's hospital by 50 per cent in only one year. It's critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns, said Dr Ana Pujols McKee, chief medical officer of The Joint Commission in a statement on their website.

Read more:

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Comments (16)
Share what you think Newest Oldest Best rated Worst rated View all Report comment Miguel, Abilene, United States, 5 hours ago Not bad news. Consider the operations performed between 2005, when most mistakes were made, and 2012, when procedures were really tightened up!! There must have been millions and millions of operations performed. This is not a perfect country, unlike the British NHS!!!

2 2 Click to rate Report comment jr23, cape coral fl usa, 8 hours ago jahco and gov inspections is mostly about paperwork. paperwork does not find problems unannounced inspection and observation does

0 8 Click to rate

Report comment Brian, chicago, United States, 8 hours ago and doctors whine about getting sued. you left a retractor inside someone and they should just shrug it off?

3 10 Click to rate Report comment Larry P., Miami Florida, United States, 9 hours ago I understand Obamacare requires at least one surgical item be left in every patient doctors choice.

8 11 Click to rate Report comment tessaronni, Seattle, United States, 10 hours ago Every operating room I've worked in the past 17 years has been doing the kind of counts described above. Sponges and, occasionally, instruments are still left behind. Many hospitals are now performing a final x-ray before the patient leaves the OR.

1 21 Click to rate

Report comment Gale Boetticher, Albuquerque, United States, 9 hours ago A final x-ray should be mandatory! 2 11 Click to rate Report comment rebeca, groves texas USA, 10 hours ago While it's a bad thing when sponges or tools are left in a patient, it happens a very small percentage of the time. According to the CDC website, there were more than 51 million surgeries performed in the US in 2012. I am a nurse and surgical tech. It is the policy at my hospital - and every facility I trained at- for 2 people , the nurse and tech usually , to count all sponges, tools, needles, hypos and blades before the case starts , if the circulating nurse or tech is relieved for lunch etc during the case it's all counted before new people join the team and before the surgeon begins to close the patient. In a C section, you count before, as soon as the baby is delivered and before the uterus is closed and then again when the incision is to be closed. Some hospitals make it their policy to X ray every patient prior to closing the wound to ensure nothing is left behind. Most OR teams work very hard to take care of their patients and keep them safe.

1 27 Click to rate Report comment Trey1, Los Angeles, 10 hours ago It's unfortunate when anyone suffers a mishap, but realistically the number of incidents will never be zero, even if human error is taken out of the picture by having robots are performing all procedures. The CDC says there are 51 million surgical procedures in the U.S. per year. So for the period from 2005-2012, approximately 350 million procedures were performed. If there were 800 incidents of objects being left behind was about 2 per every million procedures performed. That's actually pretty impressively low.

1 14

Click to rate Report comment EL, UK, 10 hours ago briton37 this is an article about america not the uk

0 5 Report comment Miguel, Abilene, United States, 5 hours ago Hot damn, there ain't sneaking nothing passed you eh???? I'm sure this never happens in the UK./ 0 2

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Click to rate Report comment Kane, perth, Australia, 10 hours ago human error isnt acceptable as an excuse in that situation.

4 5 Report comment Quand tu dors, pres de moi, Reunion, 1 hour ago

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Lots of lives are a human error... Just like in every field there is poor quality in this one too. And just like others, they all have more than work on their minds. 0 0 Click to rate Report comment iloura, Des Moines, 11 hours ago Yep. The only thing I clearly remember from my c-sections was listening to them counting the surgical rags used pre-op and post-op to make sure they matched. No thank you.

4 8 Report comment Harvey, Aberdeen, 11 hours ago

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I'm not sure what your problem is, surely you would rather hear them counting to be sure, than not counting at all and having some rather bad news afterwards?? 1 7 Click to rate The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline.

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