Surgical Tools Left in 1,500 Patients Per Year

A study done by researchers at Brigham and Women’s Hospital and Harvard School of Public Health, in Boston was published in the January 16, 2003 New England Journal of Medicine reported on the high number of surgical tools left inside patients during surgery.

The study on medical mistakes found that operating room teams around the country leave sponges, clamps and other tools inside about 1,500 patients every year, largely because of stress from emergencies or complications discovered during surgery. The researchers checked insurance records from about 800,000 operations in Massachusetts for 16 years ending in 2001. They counted 61 forgotten pieces of surgical equipment in 54 patients. From that, they calculated a national estimate of 1,500 cases yearly. A total of $3 million was paid out in the Massachusetts cases, mostly in settlements.

The study showed that two-thirds of the mistakes happened even though the equipment was counted before and after the procedure, in keeping with the standard practice. It also claimed that these types of mistakes happen more often to fat patients, simply because there is more room inside them to lose equipment.

Most lost objects were sponges, but also included were metal clamps and electrodes. In two cases, 11-inch retractors, metal strips used to hold back tissue, were forgotten inside patients. The study found that emergency operations are nine times more likely to lead to such mistakes, and operating-room complications requiring a change in procedure are four times more likely. The lost objects were usually lodged around the abdomen or hips but sometimes in the chest, vagina or other cavities. They often caused tears, obstructions or infections. One patient died of complications.

Dr. Sidney Wolfe, health research director of the public-interest lobby group Public Citizen, said the real number of lost instruments may be even higher, because hospitals are not required to report such mistakes to public agencies. Dr. Kaveh Shojania, author of a 2001 federal study on medical mistakes, summed the report up by saying, “Something has to be done about this. It’s just a very tough balance to decide.”