Mistakes and consequences
In any given typical surgery, an estimated 250–300 surgical tools are used.Institute of Medicine. ''To Err Is Human- Building a Safer Healthcare System'' pg.43 The number significantly increases to 600 when a larger surgery is performed, thus increasing the chance of the surgeon losing an instrument.Types of forgotten instruments
Frequency
The estimate of how often this type of mistake happens is unclear. According to the U.S. Department of Health and Human Services, it is anywhere between 1 in 100 to 1 in 5000. However a study done in 2008 reported to the ''Gossypiboma
Gossypiboma is the official name for a retained sponge/towel after surgery. This word comes from the Latin word for cotton, gossypium, combined with the Swahili word for place of concealment, boma.Fortia, Mohamed El, Maroua Bendaoud, and Sumer Sethi. "Abdominal Gossypiboma (Textilioma)." ''Internet Journal of Radiology'' It is also commonly referred to as textilioma. This word combines textile, meaning cloth, and the suffix –oma, which means growth or tumor. A case of gossypiboma can be subtle and may not be discovered until months or even years after the surgery has been performed. In rare cases, a situation can be so severe that it is noticed immediately. Some of the ways gossypiboma can present itself are as a mass in the body or as a bowel tumor.Zbar AP, A. Agrawal, I.T.Saeedi, and MRA Utidjian. "Gossypiboma revisited: a case report and review of the literature." Immediately after surgery, a case of gossypiboma can commonly be mistaken for an abscess, especially when it is near a passage between organs (a "fistula"). In those cases where a sponge isn't discovered until much later, it may be impossible to tell the difference between gossypiboma and an "intra-abdominal abscess". This is because both cause air bubbles and "calcification of the cavity wall." Gossypiboma is difficult to diagnose due to vague, inconsistent symptoms and images from x-rays that provide no solid evidence and unclear results. Because it is difficult to diagnose, emphasis has been put on the prevention of the mistake. The following techniques have been put into practice to prevent gossypiboma. *Radiopaque marking: Before operation, sponges can be soaked through with "radio-opaque marker". This allows a sponge to be easily seen on plain radiographs. When the markers are noticed, it can be assumed that it is revealing a retained sponge. A.P. Zbar, Surgical Directorate at Oldchurch and Harold Wood Hospitals stated "the diagnosis is easily made by plain abdominal radiography, when a radio-opaque marker is seen". This method is flawed in that it doesn't work if the sponges have broken into smaller pieces over time. *Consequences
Dangers of a tool or sponge left behind range anywhere from harmless to life-threatening. Surgical tools left in the body can puncture vital organs and blood vessels, causing internal bleeding. Sponges can fester inside a body, growing increasingly dangerous over time. Additional operations may be necessary, which can be costly and also take the surgical table away from other patients with more urgent needs. Michael Blum said "The incidents observed…took an average of 13 minutes to resolve, a time lapse which can significantly impact the flow of a busy emergency or perioperative department." Another danger is a sponge can be misdiagnosed, resulting in an unnecessary extreme surgery. A radical surgery can be avoided by considering the possibility of a retained sponge or tool.Contributing factors
Many studies have taken place to pinpoint the causes of tools being forgotten in hopes that they may be avoided in the future. It has been thought that the amount of blood lost in a surgery or the changing of nurses during the surgery would influence the risk of losing something, but studies do not support this. Human factors such as exhaustion, lack of tools necessary to aid in producing an accurate count, and a chaotic environment all have been seen to increase the risk of forgetting a tool. These factors cannot be controlled and surgeons must learn to mitigate them. Inaccurate counts are a main reason why tools can be left behind. Many cases of a retained instrument originally reported a correct sponge count when the patient was released. An inaccurate count can occur when nurses are deprived of sleep, when the operation is particularly difficult, long, and mentally draining, when the operation is an emergency, or when there are unforeseen changes in the procedure. An increased amount of chaos and distractions lead to a higher risk of a surgeon forgetting a tool. Mark Hulse from North Shore Medical Center said the following about surgery; "It's a process that's definitely subject to interruption and can be prone to errors. You're doing a hundred other things at the same time, and as much as you try to keep your attention on it ponge countsif the surgeon needs something, it's easy to get distracted." Some aspects of surgery that can add to chaos are performing unforeseen changes in the procedure and undergoing emergency surgery. Consequently, the emergency room is the place most likely to make mistakes. Studies have shown having a highRetained Surgical Instruments and Unretrieved Device Fragments (UDF)
In 2008, the US Food and Drug Administration (FDA) published a Public Health Notification advising on serious adverse events arising from fragments of medical devices left behind after surgical procedures, known as unretrieved device fragments (UDFs). The FDA's Centre for Devices and Radiological Health receives around 1000 adverse event reports each year relating to UDFs.FDA. "Unretrieved Device Fragments."Fischer, R. "Danger: Beware of Unretrieved Device Fragments." One major source of UDFs is from the failure of surgical instruments.Health Devices. "Top 10 Technology Hazards." There are many risks from UDFs. The FDA states: "The adverse events reported include local tissue reaction, infection, perforation and obstruction of blood vessels, and death. Contributing factors may include biocompatibility of the device materials, location of the fragment, potential migration of the fragment, and patient anatomy. During MRI procedures, magnetic fields may cause metallic fragments to migrate, and radiofrequency fields may cause them to heat, causing internal tissue damage and/or burns"Preventing incidents
Improvement in lowering the number of mistakes likely depends upon improving the surgical system, and not in individual scapegoating. According to the Institute of Medicine, "the problem is not bad people; the problem is that the system needs to be made safer."Institute of Medicine. ''To Err Is Human- Building a Safer Healthcare System.'' pg. 49 In order to improve the system and reduce the number of accidents, some hospitals require four counts of sponges and instruments.Berguer, Ramon and Paul J. Heller. "Preventing Sharps Injuries in the Operating Room." The first count happens when the instruments are being set up and the sponges unwrapped. The next count is required right before surgery begins, another count as closure begins, and finally a count during skin closure. This is a general guideline and there are different count methods according to different hospitals. While careful counting could prevent some mistakes, counting carries its own risks. Sometimes the patient must be worked on immediately, leaving no time to count the instruments to be used beforehand. Another risk of counting after is having to leave the patient under anesthesia longer. In addition, counting may not be entirely beneficial as counting is prone toReferences
{{reflist, refs = Grady, Denise. “Forgotten Surgical Tools 'Uncommon but Dangerous'.”Smith, Carol. “Surgical Tools Left in Five Patients.” Medical error Surgery