5 ms·

Sponges, drill bits and wires: Surgeons mistakenly left objects inside thousands

65 points by littlexsparkee 2y ago

littlexsparkee 2y ago
https://archive.ph/xm5L0 https://archive.ph/xm5L0
iancmceachern 2y ago
This is definitely a thing, they do all kinds of things like counting things before and after the surgery to avoid it.
- hulitu 2y ago
  "Dottore, still counting ? Hurry up, there are 10 more patients avaiting surgery today. The profit of the company and your bonus are in danger. Hurry up"
  - gregoryl 2y ago
    You could frame it a different way; what level of risk would be acceptable vs. the reduction in cost/time/use of resources. If you're 10% faster for 0.1% risk, is that a better outcome for society?
    - hansvm 2y ago
      You could, but the willingness to frame it that way at a local decision-making level causes problems for global optimization. It's perfectly fine for a surgeon to triage patients and actions. It's much less fine for a hospital administrator to decide they can get away with less staff because the increase in risk isn't _that_ high (maybe only a couple extra deaths per year). Perhaps it's fine to make that tradeoff, but the blatant conflict of interest and history of people doing worse things for less money suggests it should at least have oversight.
    - nkrisc 2y ago
      How would you feel being the 0.1% for the betterment of society? Your sacrifice is appreciated!
      - anonymars 2y ago
        We are all already part of this conversation, all the time, because resources are finite The flip side is "sorry, we didn't have enough surgeons available right now so we have to triage you", or, "sorry you can't afford the bill" I'm sure in this particular situation the numbers benefit "don't leave surgery debris in the patient" but the more general point remains, there is some set of numbers (likely implausible) where it would flip the other way
      - FirmwareBurner 2y ago
        Hate it all you want but these decisions of how much percentage death is legally allowed happens whether you like it or not. Otherwise we'd have no cars on the road, no planes in the sky, no boats, no swimming, no cycling, etc
      - daedrdev 2y ago
        10% faster could easily be more than 0.1% better for society. Less risk for infection or other problems, more people can be seen etc. Its entirely about weighing pros and cons and you are being ignorant by assuming otherwise.
    - collingreen 2y ago
      Society isn't a shareholder
- spondylosaurus 2y ago
  Fifteen or 20 years ago I remember seeing something about using bar codes to "check out" and "check in" all the tools so nothing was unaccounted for. Unclear if that system's been widely adopted, though.
  - duk3luk3 2y ago
    They do something like that in aircraft manufacturing - every tool has a dedicated spot in the toolbox and a job can't be signed off unless all the tools are back in the toolbox. Bolts, nuts, and other parts/debris are a different story though... there's horror stories from that as well, especially recently from one of Boeing's facilities implicated in the string of manufacturing and maintenance related incidents Boeing had in the last couple years.
giardini 2y ago
Unworthy.
rkagerer 2y ago
In the airline industry they have checklists. In Japan, train operators point and vocalize. In my volunteer fire department, we've adopted a "two sets of eyes" policy on all technical rope rigging before declaring it ready. I know humans are fallable, but I feel like there are some basic, workplace culture driven techniques that could substantially help here.
- rohan_ 2y ago
  not to be pedantic, but the examples you're describing are _process_, not _culture_. Examples of culture would be: do nurses feel comfortable speaking up / questioning the lead surgeon? do surgeons feel like they can voice when they're overworked without fear of being perceived as a failure?
- vasco 2y ago
  There's plenty of checklists in the medical field as well. Specially during triage of all kinds. The main issue is that in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down. Think about your own work and you'll find reasons why checklists don't make sense, I bet. I once went in for a surgery on a foot and when rolled into the room the doctor asked me if I had any last minute questions and I asked only 'which foot are you operating on'. After a few seconds of confusion he gave a decisive right answer and even told me 'here, if it makes you feel better I'll sharpie your leg'. And it did make me feel better - there's so much that can easily go wrong by a minor mistake from them which will be life changing for you.
  - recursivecaveat 2y ago
    Usually they are supposed to pro-actively ask you that I think. When I had a fracture in my upper arm everyone would ask me which arm it was. The patient is a good independent backup for easy flip/flop errors.
    - energy123 2y ago
      Error correction
hhh 2y ago
My mother had rags left in her during a surgery that ended up fucking up the course of her life forever and leaving her permanently disabled. The rags didn’t cause the primary problem, but were just a part of their shoddiness. Of course it’s not every surgeon, but there are some butchers that out happens more with. It ended up being a repeat problem for my mother’s surgeon.
logicchains 2y ago
Not all surgeons are alike, just as in any profession: some make many errors and some make few. But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions about their surgical provider, which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market.
- rscho 2y ago
  > But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions Yes. > which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market This is absolutely not why the 'doctors unions' fight against performance statistics. Can't you people think of nothing else than money ?
  - silexia 2y ago
    Doctors unions also have strictly limited the number of seats in medical schools in order to limit the number of new doctors and keep their pay extremely high.
- skeeter2020 2y ago
  unlucky for you we have a control group with Canada's public health system where surgeons still leave things inside people and no efficient market to "weed them out" so I don't think this is correct
Hojojo 2y ago
I wonder how the frequency compares with other countries. Is this as common in Europe or in Asia? Or even Mexico or Canada?
keepamovin 2y ago
Seems there should be a "check in" "check out" list, managed by one of the other staff, and double checked by another, ideally. Or even some form of RFID tagging and a scan wand.
- eszed 2y ago
  In my previous life I once taught a theatre production class in which one of my students was a surgical nurse. She was fascinated by the prop table. For those of you who don't know, standard procedure - at least with every Stage Manager with whom I ever worked - for a prop table is to draw an outline around every item, which in one step defines a place for everything and allows one-glance inventory assessment. Well, this nurse said she hadn't seen or thought of that approach, which would speed up and make more reliable the "count in and count out every surgical instrument" part of her role, and she vowed on the spot to implement it at work. It's the only time in my theatre career I might have maybe indirectly saved a life.
  - rkagerer 2y ago
    I do the same for my wall of tools, and it's also helped my partner remember to put them back after she borrows one. (But it makes me grumpy when one gets lost and I can't find a replacement that's the same size and shape).
  - keepamovin 2y ago
    That’s a brilliant idea that’s exactly what it should be! Wow, how about we found a medical device company that’s like a table that will let you know when the device it needs is not back on the table? Seriously I always wanna get into hardware. cris@dosaygo.com Though honestly, I’m sure you saved many other lives directly or not by theater that speaks to people, that they can identify with.
bell-cot 2y ago
At least in America, surgeons are part of an entitled medical elite, and there is tragically little interest in holding them to account. Let alone forcing them to do better.
leguminous 2y ago
When my wife had some minor surgery (not fully anesthetized), there was a nurse present who counted all of the sponges, etc. that were used, then made sure there were that many on the tray at the end. They didn't match up, and it turned out that the surgeon had dropped one off of the table. The article mentions that counting is standard procedure, so hopefully this is how it works everywhere. It definitely seems like having someone who isn't the surgeon doing the counting would be the way to go. The surgeon is already very focused and it's easier to say "I'm sure I didn't leave anything" when someone else isn't telling you otherwise.
- npsomaratna 2y ago
  Doctor here (non-USA). This is standard procedure and has been standard ever since I was a medical student, almost 20 years ago. The "running nurse" is in charge of maintaining a count and making sure that nothing is left inside the patient. Swabs and towels tend to come in pre-prepared packs, so the nurses have another source of truth. Any mismatch between the preprepared count, running count during the operation, and actual swabs/towels laid out at the end is a serious cause for concern. You will not close up a patient if there is a mismatch.
- matwood 2y ago
  Yeah, back in the late 90s I was able to observe a number of surgeries (different story) and I remember the counting being almost fanatical. They had what looked like a shoe holder that hung on a door for putting each rag that was used. Every instrument that was used was accounted for during and after. The surgeon was definitely not the counter.
  - aelhage 2y ago
    My wife is an OR nurse and jokes her primary job responsibility is counting. Frequently when surgery is going long it's because someone threw out or dropped something that was supposed to be accounted for and they won't close the patient up until that's found, even if that means sorting through the garbage.
selcuka 2y ago
This sounds like the perfect application of image processing and machine learning. A computer with a camera attached could monitor the whole operation and warn the surgeon if it detects an object going in but not out. At least it would be more useful than the system they use for self checkouts at my local supermarket. "Did you forget to scan something in your trolley?" Yes, it's my child.
- skeeter2020 2y ago
  maybe? If you've every seen a non-trivial surgery there are lots of people, action and "things inside you". I'm not convinced we should or even can optimize for camera field of view and ML - especially when this feels more like an accounting problem than an image processing problem.
7a1c9427 2y ago
As a comparison in the UK there is robust mandatory reporting on "Retained foreign object post procedure" which is a so-called "Never Event" in the most recent publication (April 2024 to September 2024) this occurred 60 times[1] in the NHS in England. For a denominator there are approximately 21 million operation performed in a year by NHS England[2]. So roughly 0.002% of cases have an unintended retained object or roughly 1 in 50,000. For further reading the Health Services Safety Investigations Body in the UK (like the NTSB but for healthcare incidents is the best worst analogy) looked at retained foreign objects and published in 2024: https://www.hssib.org.uk/patient-safety-investigations/retained-surgical-swabs/ https://www.hssib.org.uk/patient-safety-investigations/retai... [1]: https://www.england.nhs.uk/long-read/provisional-publication-of-never-events-reported-as-occurring-between-april-2024-and-september-2024/ https://www.england.nhs.uk/long-read/provisional-publication... [2]: https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2023-24 https://digital.nhs.uk/data-and-information/publications/sta...
woleium 2y ago
https://archive.is/XeY5j https://archive.is/XeY5j

littlexsparkee 2y ago

https://archive.ph/xm5L0 https://archive.ph/xm5L0

iancmceachern 2y ago

This is definitely a thing, they do all kinds of things like counting things before and after the surgery to avoid it.

hulitu 2y ago
"Dottore, still counting ? Hurry up, there are 10 more patients avaiting surgery today. The profit of the company and your bonus are in danger. Hurry up"
- gregoryl 2y ago
  You could frame it a different way; what level of risk would be acceptable vs. the reduction in cost/time/use of resources. If you're 10% faster for 0.1% risk, is that a better outcome for society?
  - hansvm 2y ago
    You could, but the willingness to frame it that way at a local decision-making level causes problems for global optimization. It's perfectly fine for a surgeon to triage patients and actions. It's much less fine for a hospital administrator to decide they can get away with less staff because the increase in risk isn't _that_ high (maybe only a couple extra deaths per year). Perhaps it's fine to make that tradeoff, but the blatant conflict of interest and history of people doing worse things for less money suggests it should at least have oversight.
  - nkrisc 2y ago
    How would you feel being the 0.1% for the betterment of society? Your sacrifice is appreciated!
    - anonymars 2y ago
      We are all already part of this conversation, all the time, because resources are finite The flip side is "sorry, we didn't have enough surgeons available right now so we have to triage you", or, "sorry you can't afford the bill" I'm sure in this particular situation the numbers benefit "don't leave surgery debris in the patient" but the more general point remains, there is some set of numbers (likely implausible) where it would flip the other way
    - FirmwareBurner 2y ago
      Hate it all you want but these decisions of how much percentage death is legally allowed happens whether you like it or not. Otherwise we'd have no cars on the road, no planes in the sky, no boats, no swimming, no cycling, etc
    - daedrdev 2y ago
      10% faster could easily be more than 0.1% better for society. Less risk for infection or other problems, more people can be seen etc. Its entirely about weighing pros and cons and you are being ignorant by assuming otherwise.
  - collingreen 2y ago
    Society isn't a shareholder
spondylosaurus 2y ago
Fifteen or 20 years ago I remember seeing something about using bar codes to "check out" and "check in" all the tools so nothing was unaccounted for. Unclear if that system's been widely adopted, though.
- duk3luk3 2y ago
  They do something like that in aircraft manufacturing - every tool has a dedicated spot in the toolbox and a job can't be signed off unless all the tools are back in the toolbox. Bolts, nuts, and other parts/debris are a different story though... there's horror stories from that as well, especially recently from one of Boeing's facilities implicated in the string of manufacturing and maintenance related incidents Boeing had in the last couple years.

giardini 2y ago

Unworthy.

rkagerer 2y ago

In the airline industry they have checklists. In Japan, train operators point and vocalize. In my volunteer fire department, we've adopted a "two sets of eyes" policy on all technical rope rigging before declaring it ready. I know humans are fallable, but I feel like there are some basic, workplace culture driven techniques that could substantially help here.

rohan_ 2y ago
not to be pedantic, but the examples you're describing are _process_, not _culture_. Examples of culture would be: do nurses feel comfortable speaking up / questioning the lead surgeon? do surgeons feel like they can voice when they're overworked without fear of being perceived as a failure?
vasco 2y ago
There's plenty of checklists in the medical field as well. Specially during triage of all kinds. The main issue is that in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down. Think about your own work and you'll find reasons why checklists don't make sense, I bet. I once went in for a surgery on a foot and when rolled into the room the doctor asked me if I had any last minute questions and I asked only 'which foot are you operating on'. After a few seconds of confusion he gave a decisive right answer and even told me 'here, if it makes you feel better I'll sharpie your leg'. And it did make me feel better - there's so much that can easily go wrong by a minor mistake from them which will be life changing for you.
- recursivecaveat 2y ago
  Usually they are supposed to pro-actively ask you that I think. When I had a fracture in my upper arm everyone would ask me which arm it was. The patient is a good independent backup for easy flip/flop errors.
  - energy123 2y ago
    Error correction

hhh 2y ago

My mother had rags left in her during a surgery that ended up fucking up the course of her life forever and leaving her permanently disabled. The rags didn’t cause the primary problem, but were just a part of their shoddiness. Of course it’s not every surgeon, but there are some butchers that out happens more with. It ended up being a repeat problem for my mother’s surgeon.

logicchains 2y ago

Not all surgeons are alike, just as in any profession: some make many errors and some make few. But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions about their surgical provider, which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market.

rscho 2y ago
> But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions Yes. > which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market This is absolutely not why the 'doctors unions' fight against performance statistics. Can't you people think of nothing else than money ?
- silexia 2y ago
  Doctors unions also have strictly limited the number of seats in medical schools in order to limit the number of new doctors and keep their pay extremely high.
skeeter2020 2y ago
unlucky for you we have a control group with Canada's public health system where surgeons still leave things inside people and no efficient market to "weed them out" so I don't think this is correct

Hojojo 2y ago

I wonder how the frequency compares with other countries. Is this as common in Europe or in Asia? Or even Mexico or Canada?

keepamovin 2y ago

Seems there should be a "check in" "check out" list, managed by one of the other staff, and double checked by another, ideally. Or even some form of RFID tagging and a scan wand.

eszed 2y ago
In my previous life I once taught a theatre production class in which one of my students was a surgical nurse. She was fascinated by the prop table. For those of you who don't know, standard procedure - at least with every Stage Manager with whom I ever worked - for a prop table is to draw an outline around every item, which in one step defines a place for everything and allows one-glance inventory assessment. Well, this nurse said she hadn't seen or thought of that approach, which would speed up and make more reliable the "count in and count out every surgical instrument" part of her role, and she vowed on the spot to implement it at work. It's the only time in my theatre career I might have maybe indirectly saved a life.
- rkagerer 2y ago
  I do the same for my wall of tools, and it's also helped my partner remember to put them back after she borrows one. (But it makes me grumpy when one gets lost and I can't find a replacement that's the same size and shape).
- keepamovin 2y ago
  That’s a brilliant idea that’s exactly what it should be! Wow, how about we found a medical device company that’s like a table that will let you know when the device it needs is not back on the table? Seriously I always wanna get into hardware. cris@dosaygo.com Though honestly, I’m sure you saved many other lives directly or not by theater that speaks to people, that they can identify with.

bell-cot 2y ago

At least in America, surgeons are part of an entitled medical elite, and there is tragically little interest in holding them to account. Let alone forcing them to do better.

leguminous 2y ago

When my wife had some minor surgery (not fully anesthetized), there was a nurse present who counted all of the sponges, etc. that were used, then made sure there were that many on the tray at the end. They didn't match up, and it turned out that the surgeon had dropped one off of the table. The article mentions that counting is standard procedure, so hopefully this is how it works everywhere. It definitely seems like having someone who isn't the surgeon doing the counting would be the way to go. The surgeon is already very focused and it's easier to say "I'm sure I didn't leave anything" when someone else isn't telling you otherwise.

npsomaratna 2y ago
Doctor here (non-USA). This is standard procedure and has been standard ever since I was a medical student, almost 20 years ago. The "running nurse" is in charge of maintaining a count and making sure that nothing is left inside the patient. Swabs and towels tend to come in pre-prepared packs, so the nurses have another source of truth. Any mismatch between the preprepared count, running count during the operation, and actual swabs/towels laid out at the end is a serious cause for concern. You will not close up a patient if there is a mismatch.
matwood 2y ago
Yeah, back in the late 90s I was able to observe a number of surgeries (different story) and I remember the counting being almost fanatical. They had what looked like a shoe holder that hung on a door for putting each rag that was used. Every instrument that was used was accounted for during and after. The surgeon was definitely not the counter.
- aelhage 2y ago
  My wife is an OR nurse and jokes her primary job responsibility is counting. Frequently when surgery is going long it's because someone threw out or dropped something that was supposed to be accounted for and they won't close the patient up until that's found, even if that means sorting through the garbage.

selcuka 2y ago

This sounds like the perfect application of image processing and machine learning. A computer with a camera attached could monitor the whole operation and warn the surgeon if it detects an object going in but not out. At least it would be more useful than the system they use for self checkouts at my local supermarket. "Did you forget to scan something in your trolley?" Yes, it's my child.

skeeter2020 2y ago
maybe? If you've every seen a non-trivial surgery there are lots of people, action and "things inside you". I'm not convinced we should or even can optimize for camera field of view and ML - especially when this feels more like an accounting problem than an image processing problem.

7a1c9427 2y ago

As a comparison in the UK there is robust mandatory reporting on "Retained foreign object post procedure" which is a so-called "Never Event" in the most recent publication (April 2024 to September 2024) this occurred 60 times[1] in the NHS in England. For a denominator there are approximately 21 million operation performed in a year by NHS England[2]. So roughly 0.002% of cases have an unintended retained object or roughly 1 in 50,000. For further reading the Health Services Safety Investigations Body in the UK (like the NTSB but for healthcare incidents is the best worst analogy) looked at retained foreign objects and published in 2024: https://www.hssib.org.uk/patient-safety-investigations/retained-surgical-swabs/ https://www.hssib.org.uk/patient-safety-investigations/retai... [1]: https://www.england.nhs.uk/long-read/provisional-publication-of-never-events-reported-as-occurring-between-april-2024-and-september-2024/ https://www.england.nhs.uk/long-read/provisional-publication... [2]: https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2023-24 https://digital.nhs.uk/data-and-information/publications/sta...

woleium 2y ago

https://archive.is/XeY5j https://archive.is/XeY5j