Sponges, Tools And More Left Inside Washington Hospital Patients

Aug 5, 2013

About 30 times a year, a surgery patient in Washington state has a sponge or surgical instrument left inside them. It’s one of the most commonly reported medical mistakes.

University of Washington surgical technician Maurice Lybarger counting sponges.
Credit John Ryan

Anesthesiologist: “We’re just going to give you a little bit of oxygen, okay? Nice slow, deep breaths here. You’re doing great. All right?”

At the University of Washington Medical Center, a surgical team is prepping a 49-year-old man for a hernia repair. Before they cut into his abdomen, they go though a long checklist of preparations. They’re designed to minimize the chance of harming the patient that the hospital’s trying to help.

Anesthesiologist: “Cushing vein retractors?” “Two” “Gelpies? “Two…”

A big part of the prep-work is a careful count of every piece of metal or cloth or plastic that might end up inside the patient during surgery.

Anesthesiologist: “Sponges?” “1,2,3,4,5,6,7,8,9,10.”

And they’ll do the same count after the surgery’s done to make sure nothing’s gone missing. Checklists and counts have been widely adopted by hospitals in recent years. But medical mistakes remain a leading cause of death and injury nationwide.

The numbers fluctuate year to year. Five years in a row, UW Med Center had the state’s worst record of leaving things inside its patients. Then last year, UW had a perfect record: Nobody came out of surgery with a retractor or sponge or anything else left inside them. Hospitals with Multicare in south Puget Sound and Swedish in Seattle left the most objects in their patients last year. It happened six times at Multicare and five at Swedish. Now, these hospitals do thousands of surgeries each year.

Vassall: “So it’s really an uncommon event.”

Dr. John Vassall is chief medical officer at Swedish. He and other health care experts say such egregious errors shouldn’t be uncommon. They should never happen.

Vassall: “We’ve been working diligently on a daily basis to reduce harm to our patients.”

Vassall says the system of pausing to count sponges and instruments isn’t as straightforward as you might think.

Vassall: “It works, but it’s not perfect. Part of reason for that is when you’re counting the sponges at beginning, the sponges are nice and clean and white and sterile. I don’t want to get too graphic for your listeners.”

Aw, that’s okay. We can handle it.

Vassall: “When you’re counting at the end, they have blood on them, the color’s different, they blend in with the tissues. It’s a lot harder to find and count them.”

Eww. Hospitals have tried to make it easier for surgical teams to eyeball the balled-up, blood-soaked sponges that they’ve stuffed inside a patient. Tom Varghese is a chest surgeon at UW.

Varghese: “We have these sort of hanging racks where you actually put the sponges in a visual display. The surgical team can actually look and say, yes, those are the actual sponges that were used.”

While few hospitals have adopted it, there’s also a high-tech fix for missing sponges.

Reed: “That almost never happens now. It’s incredibly rare, if new technology’s used.”

Dr. Lester Reed is in charge of patient safety at Multicare. The Tacoma hospital chain now uses electronically enhanced sponges. Inside each sponge is a radio-frequency tag about the size of a grain of rice. During surgery, they can wave an electronic wand over the patient. If any sponges are hiding inside, it lets them know. The Bellevue-based manufacturer says the sponge-tracking system costs about $10 per surgery. The main problem: it’s a lot easier to embed electronics inside a sponge than in a retractor made of steel. Reed and other doctors say there’s something more important than any technology in making hospitals safer.

Reed: “Communication really rests, we now know, at the heart of almost all medical errors, in one way or another. It’s communication.”

Hospitals are hierarchies, and in an operating room, the surgeon is still the alpha dog. It can be intimidating for others to speak up.

Reed: “These aren’t physicians who are screaming at patients or at nurses. It’s a subtlety, it’s the subtlety of arrogance that might be present.”

Reed says Tacoma General and the other Multicare hospitals have been working for the past five years to improve the way doctors and nurses interact. When Tacoma General left a retractor inside a patient last year, an internal review pointed to poor communication between a male surgeon and an unidentified nurse.

Reed: “In this particular case, she or he didn’t quite feel comfortable enough to say, ‘I don’t think something’s right here.'"

Reed says the lost retractor led Multicare to change its tool-counting procedures. The surgeon involved no longer works at Tacoma General. Back at the University of Washington, preparations for the hernia surgery continue. Surgeon Patch Dillinger orders his seven coworkers to speak up.

Dillinger: “Anybody with questions? Concerns? Anyone w/concerns you must speak up immediately, otherwise we’re ready to roll.”

The team takes a second safety pause. This time, they do something even simpler than counting sponges. They introduce themselves. It’s not rocket science, but sometimes just knowing somebody’s name makes it easier to talk to them.

Vassall: “Something as simple as that reduces a number of errors.”

John Vassall with Swedish explains why so many hospitals use these ice-breaking introductions before surgery.

Vassall: “In the past, it would be very difficult for a nurse or, say, an environmental services worker to stop a doctor and say I don’t think this is right, and in many places that’s still the case. But now we understand unless we’re watching each other and being accountable and careful about each other’s actions, then we can't have a safe system.”

When it comes to external communication about their mistakes, hospitals are less interested in people speaking up. Many hospitals say they embrace transparency as a tool for learning and growing safer. But when a patient or their survivors settle a medical negligence lawsuit with a hospital, the hospital usually seeks a gag order, to keep them from talking about their settlement.

Roberts: “Confidentiality clauses are very commonly requested, and they’re often agreed to.”

Nathan Roberts is a trial lawyer in Tacoma. He often represents victims of medical mistakes.

Ryan: Hospitals are essentially agreeing to pay for silence?

Roberts: “Correct. I think they don’t want the embarrassment out in the public light, and they don’t want people to know about their fatality rates and about their injury rates. They don’t want to scare people.”

A spokeswoman for the Washington State Hospital Association says most companies use confidentiality agreements when they settle lawsuits, and hospitals are no different.

Copyright 2013 KUOW