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More Errors Found In Emergency Surgery

Study Looks At Cases In Which Equipment Was Left In Patients

Jan 16, 2003 | The Boston Globe

Doctors are far more likely to leave surgical equipment inside patients under the pressure and chaos of emergency surgery than during typical operations, according to a new study of Massachusetts hospitals that suggests that safety protocols need to be strengthened.

Though such mistakes are rare, leaving sponges, scissors, and other tools within sewn-up patients can cause significant harm.

The authors of the study investigated 54 malpractice cases involving equipment left inside patients at 10 Massachusetts hospitals between 1985 and 2001. In those incidents, one patient died and others suffered serious infections or bowel damage. Most cases ended with successful removal of the objects in a second operation.

The authors estimated that 1,500 similar errors occur annually in US hospitals, a small risk, given the tens of millions of surgeries occurring each year. Put another way, the errors occur in 1 of every 9,000 to 19,000 surgeries where the body cavity is opened.

The study underscores that life-and-death emergencies can distract even the most adept surgical team, highlighting one of the many types of medical errors that have caused a recent erosion of public confidence in doctors.

''If you have an emergency operation, you can imagine someone is bleeding, you're rushing them to the operating room, and the nurse has many responsibilities now, not only to help the surgeon open the patients, but to count every piece of equipment twice,'' said the study's author, Dr. Atul A. Gawande, a surgeon at Brigham and Women's Hospital. ''With someone bleeding, you're going to move fast and do everything you can to take care of the patient. It's not surprising that you'd miss something.''

Gawande, who moonlights as a writer for The New Yorker magazine, has made doctor error and fallibilty the leitmotif in his writing. He recently wrote a book of essays, ''Complications: A Surgeon's Notes on an Imperfect Science,'' and said he views today's study, published in the New England Journal of Medicine, as a technical complement to his literary work.

''What we know about errors is that they occur in the hands of good doctors,'' he said.

Gawande's team studied six years of malpractice lawsuits involving an insurance firm that covers a third of the state's doctors. They found 54 cases involving 61 items left in patients. Two-thirds of the items were sponges, while the rest involved clamps, electrodes, and other surgical devices.

They compared these cases to similar surgeries that were error-free, allowing them to determine if certain factors were more prevalent in the botched surgeries.

Emergency operations unpredictable, unplanned surgeries requiring almost immediate operation were nine times as likely to result in objects left in patients, they found. Also, errors were four times more likely to occur after procedures involving unexpected changes, usually when doctors discovered new ailments during surgery.

Larger-bodied patients, with more space for surgical tools to lodge in, were more likely to be victims of errors, the researchers found. However, patient age, the time of the surgery, or the degree of complexity had no impact on error rate.

Fifty-four percent of the sponges and surgical tools in the error cases were left in the abdomen or pelvis, 22 percent in vaginas, 7 percent in the chest, and the rest in various bodily regions, including the face and brain.

Three cases were discovered the day after the surgeries, but 14 cases took almost two months to rectify, with the median detection time 21 days. The average payout to patients in the lawsuits prompted by the errors was $52,581.

Most hospitals only require that two nurses count all equipment twice before and twice after surgery. But that isn't foolproof: In 88 percent of the error cases, the nurses reported all the equipment had been accounted for.

''The way to further reduce these errors from happening is to step up the use of X-rays, CT scans, and other radiographic technologies to ensure that surgical objects are not left behind,'' Gawande said.

He also suggested that surgical tools and sponges be stamped with a code that would activate an alarm if they left the surgical suite inside a patient, like the antitheft sensors found in many stores.

But Dr. Richard Wiklund of Massachusetts General Hospital, who oversees day-to-day affairs of the hospital's 50 operating rooms, said that extra X-ray time would add enormous costs to already-strapped hospital budgets.

''I'm not sure that I could support [the study's] recommendation for all cases,'' he said, adding that no device-in-patient errors have occurred at Mass. General in the two years that he has run the operating rooms.

Wiklund said his patient safety efforts were focused on ensuring safe blood transfusions and making sure that surgeons perform the right operations on the right patients.

''These are more pressing problems,'' he said.

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