6000 patients a year leave U.S. operating rooms with surgical sponges, forceps, and other surgical tools left inside them. They won’t realize it until they develop a life-threatening infection
Erica Parks knew something wasn’t right in her belly when she left the Alabama hospital that performed her cesarean section in the spring of 2010.
Over the next month, her stomach grew so swollen that she looked pregnant again. By the sixth week, her bowels had shut down entirely. Parks, an Air Force major, staggered in to see her doctor, who sent her immediately to the emergency room.
X-rays showed that a surgical sponge the size of a washcloth had been left in Parks’ abdomen. After a six-hour emergency surgery to untangle the infected mass from her intestine, she needed nearly three weeks of hospitalization.
Parks, now 40, had suffered from what is known officially as a “retained surgical item” — a sponge or instrument left in a patient’s body. Such mistakes are considered so egregious and so preventable that they’re referred to in the medical world as “never events.” They simply are not supposed to
Thousands of patients a year leave the nation’s operating rooms with surgical items in their bodies. And despite occasional tales of forceps, clamps and other hardware showing up in post-operative X-rays, those items are almost never the problem. Most often, it’s the gauzy, cotton sponges that doctors use throughout operations to soak up blood and other fluids, a USA TODAY examination shows.
Yet thousands of hospitals and surgical centers have failed to adopt readily available technologies that all but eliminate the risk of leaving sponges in patients.
The consequences are enormous. Many patients carrying surgical sponges suffer for months or years before anyone determines the cause of the searing pain, digestive dysfunction and other typical ills. Often, by the time the error is discovered, infection has set in.
The complications can last a lifetime. Some victims lose parts of their intestines; some don’t survive.
“I thought hospitals had procedures and checks so these problems couldn’t happen in this day and age,” Parks says. “I’m still not 100%; I don’t know if I ever will be. I still have to take medicine that keeps your (digestion) flowing. They told me there might be repercussions if I try to have another kid. It’s been a terrible ordeal.”
A USA TODAY review of government data, academic studies and legal records suggests that far more people may be victims of lost surgical objects than federal statistics suggest. And the medical community’s inaction comes at a high price.
Thousands of victims: There’s no federal reporting requirement when hospitals leave sponges or other items in patients, but research studies and government data suggest it happens between 4,500 and 6,000 times a year. That’s up to twice government estimates, which run closer to 3,000 cases, and sponges account for more than two-thirds of all incidents.
Solutions ignored: The nation’s hospitals have balked at using electronic technologies that sharply cut the risk of sponges being left in patients. Fewer than 15% of U.S. hospitals use sponges equipped with electronic tracking devices, based on a USA TODAY survey of the companies that make those products.
Costly consequences: Hospitalizations involving a lost sponge or instrument average more than $60,000, according to data compiled by Medicare, which denies payment for costs stemming from such errors. Related malpractice suits cost hospitals, on average, between $100,000 and $200,000 per case, several research studies show.
A decade ago, a landmark report on health care quality ranked lost sponges and instruments in the most serious category of medical errors. Issued by the National Quality Forum, a congressionally funded non-profit, the report urged immediate steps to drive down incidence rates, including mandatory reporting to track cases.
Today, there still is no national reporting mandate, and the available data suggest little or no progress in curbing incidence rates, particularly for sponges.