NCPA - National Center for Policy Analysis

What Surgeons Leave Behind Costs Some Patients Dearly

March 11, 2013

More than 12 times per day, a surgeon will sew up a patient with a sponge or instrument left in a patient's body. Situations where "retained surgical items" are left in patients are considered so egregious that they are referred to as "never events," something that should never happen. Despite the severity of the event, it happens too frequently and must be addressed, says USA Today.

  • Complications from the lost tool can be very serious and last a lifetime, or in extreme cases lead to death.
  • Thousands of patients leave operating rooms with items in their bodies, such as clamps or forceps, but these items rarely cause a problem.
  • The most dangerous supplies left in patients are medical gauze and cotton sponges, which can cause searing pain, digestive dysfunction and other ills before starting an infection.

The National Quality Forum, a congressionally funded nonprofit, issued a report a decade ago ranking lost sponges and instruments as the most serious category of medical error.

  • Studies suggest that it happens between 4,500 and 6,000 times per year, twice the federal government's official estimate of 3,000 cases.
  • Hospitalization involving a lost sponge or instrument costs an average of more than $60,000 according to Medicare data.
  • Several research studies show that medical malpractice suits cost hospitals an average of $100,000 to $200,000 per case.

A viable solution uses electronic technologies that track tiny pieces of metal in the sponges but fewer than 15 percent of U.S. hospitals currently use this technology.

  • The sponge-tracking systems typically add about $8 to $12 to the cost of an operation.
  • Hospitals that were originally doubtful of the technology have experienced a dramatic reduction in retained surgical items following adoption of the tracking technologies.
  • Doctors, nurses and surgeons typically rely on sponge counts -- a count of what comes into the room and what comes out -- but these counts have failed to show anything amiss in 68 percent of the cases where a sponge was lost.

The Mayo Clinic says that the complexity of surgery means that there are going to be mistakes.  And hospitals record just 1 percent of the events they are supposed to record to states. Only 600 of the nation's 4,200 hospitals have installed a sponge-tracking system, which pays for itself many times over.

Source: Peter Eisler, "What Surgeons Leave Behind Costs Some Patients Dearly," USA Today, March 8, 2013.


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