Making Sure Surgeons Leave Less Behind…Inside Patients

When patients undergo surgery, they do so with the hope of becoming better, of recovery from some condition that requires physical repair or removal. No one, however, expects to leave the hospital with a little something extra–especially if that something is a sponge, forceps, or other surgical instrument left behind inside the body.

This problem isn’t common, but it is not rare, either. In fact, there have even been television shows based some true cases (such as “When Surgical Tools Get Left Behind”). Scientists estimate that about 1,500 people have surgical objects accidentally left inside them each year in the United States. Unlucky patients have been given a variety of these souvenirs of their procedures, including towels, retractors, and knives–some as large as 10 inches.

Now, this dangerous problem may soon disappear. According to an article on ScienceDaily, the University of Michigan Health System has created a new system using state-of-the-art technologies to insure that no foreign objects are left behind during surgery, reducing potentially serious medical errors.

The standard way that surgical teams have kept track of all their equipment is by counting. If you start the surgery with two scalpels, ten sponges, and a forceps, then a count at the end of the surgery should match. But in some surgeries, counting is a system that doesn’t work well (or isn’t performed well)–especially those that are complex and require the use of a large number of tools, or which involve emergency care.

“Having a foreign object left behind during surgery is something we consider a ‘never event,’ ” says Ella Kazerooni, M.D., M.S., professor of radiology at the U-M and associate chair of clinical affairs at the U-M Health System. “It’s something that should never happen.

The new U-M methods include using bar-coded sponges and electronic x-ray orders. Sponges are the most frequent item left behind in patients–bar-coded sponges are scanned when used, then scanned when removed, with the computer doing the counting and matching. In addition, these sponges contain a radiopaque tag, which can be seen on an x-ray. So instead of having the surgical team go hunting for a missing sponge, a quick x-ray (using the new digital order system) can locate the sponge within the patient’s body. In addition, a quick x-ray is critical to shorten surgery time and limit the amount of anesthesia.

We are all for anything that improves the safety of patients. Let’s hope these advances catch on nationwide.

To read the full article on ScienceDaily, click here:  Did Your Surgeons Miss Something?

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