In a screaming red headline on the front page of USA Today’s Weekend edition, Peter Eisler reports, “What surgeons leave behind.” This article re-ignites one of the most common concerns on surgical safety; retained surgical items (RSI) or gossypiboma. Along with wrong-site surgery, retained or forgotten surgical instruments are one of the catastrophic errors or medical mistakes that can occur in the operating room.
The fact that this is still occurring thousands of times a year in the United States despite multiple strategies specifically designed to address this issue is alarming. While there is federally mandated reporting, the exact numbers are in dispute, but no one argues that even one case is one case too many.
Some of the preventative strategies include documenting systems such as the surgical safety checklist, instrument counts and the radio-opaque tagging of items for identification on x-ray films. Newer strategies include electronic tagging of surgical supplies, as mentioned in Eisler’s article.
While Eisler's article details what can happen to patients who leave the operating room with items like surgical sponges or instruments left inside, these stories of life-threatening or fatal infections neglect crucial aspects. The how and why of this phenomena are equally important.
How it happens
Picture this scene; as you’ve seen it depicted thousands of times on both reality and scripted dramas. A patient comes racing in by ambulance to the emergency department. Or maybe it’s a scheduled procedure. Now replace all the attractive eye candy; all of the McDreamy-like characters, the feisty nurse stereotypes and gleaming surroundings with your local facility.
Bigger patients, more places to lose instruments
Instead of a dramatic, yet tragic waif-like figure, make the patient your next door neighbor; just an average Joe, perhaps a couple of pounds overweight and maybe even a lot more than that. According to several studies including a famous 2003 study conducted by Dr. Atul Gawande, and published in the New England Journal of Medicine, obesity is a big risk factor in these surgeries, along with abdominal surgeries in general. That’s because the abdominal cavity is a large, basically squishy place where surgical towels, clamps and small needles can easily disappear; particularly if the patient’s abdomen is larger than average. Often surgeons place towels to help displace tissue or staunch bleeding during the procedure. The larger towels or ‘laps’ as they are called often have loops or a long radiopaque stripe to help prevent these items from being lost.
Smaller items are more frequently lost
But smaller squares, or gauze sponges are just a few inches in diameter. These sponges are the ones that if certain steps aren’t taken, can be more easily overlooked, as they disappear into the depths of a body cavity and become coated with fluids; further camouflaging themselves within. Smaller items like surgical needles are also more commonly lost.
This graphic report by an author in India, illustrates the landscape in vivid color photographs.
Why it happens
Operating rooms are very busy places; with most of staff performing multiple functions during surgeries. The anesthesiologist for example, may observe the administration of anesthesia and sedation by a nurse anesthetist before moving on to the next room, to another, similar scenario. During the case, the nurse anesthetist will be responsible for monitoring vital signs, administering fluids, drawing labs and charting. In more specialized cases, these duties may include performing specialized tests like echocardiograms. In the middle of all this, double checks and signatures are needed for intravenous drugs and blood products.
The surgeon is spared much, but not all of the multi-tasking. But the circulating nurse and the surgical assistant/ scrub nurse who are the most instrumental in keeping track of surgical tools and sponge counts are often inundated with multiple tasks simultaneously. Circulators are responsible for answering phones, retrieving and ordering supplies, frequent documentation and family updates in addition to maintaining records on what supplies are in use, and inside the patient at any given time. While many operating rooms continuously update this information on a white-board inside the operating room, i.e. “Three laps in the chest”, this task can fall by the wayside in moments, should the surgery take an unforeseen turn. The scrub nurse runs the operating room table, handing instruments to the surgeon and his assistant(s), while preparing instruments and equipment in anticipation of the surgeons’ needs. It’s a fine balance that can be taxed, particularly during exceptionally long cases or change of shift.
In an era of health care personnel shortages and cost-cutting strategies, many operating rooms have limited staff, stretching manpower to the breaking point; day after day after day. This contributes to fatigue and a potential increased incidence of errors.
Changing the culture
However, one of the biggest impediments to implementing specific strategies to prevent more of these surgical errors is the punitive culture. “Near-misses” are an important aspect in developing and maintaining safety standards in any industry, particularly healthcare. However, reporting a ‘near-miss’ often results in punitive repercussions against employees or the surgical team. Government agencies such as Medicare have responded to the phenomenon by raising the stakes further, and refusing to pay for any treatment that results from this type of surgical error, further disincentivising hospitals and health care providers from reporting their mistakes.
Cooperation not condemnation
Instead, a more cooperative approach is needed; one where hospital staff and facilities who have had multiple retained surgical items can troubleshoot to find better solutions to address failures in individual systems at a facility level. Multiple studies have shown this approach to more effective at identifying and correcting breaches in technique.
Famous author – surgeon, Dr. Atul Gawande has been a strong advocate in this area, performing and publishing several studies, articles, books and lectures in an attempt to promote more stringent surgical safety by changing both the culture and the procedures used to safeguard patients.
Instead of relying primarily on gadgetry, techniques that incorporate both the opinions and experiences of healthcare personnel like Dr. Gawande with new technologies may be the most effective method for keeping patients safe.