A Medical Student Blog

Unofficial thoughts on medicine and medical school

Surgical Errors Part I: Leaving Tools Inside the Patient’s Body (by accident)

        Dear All,                                                          4/3/07 

I went to a talk by Dr. Atul Gawande, a surgeon, author and professor at Harvard.   For those of you who have never heard of him, he’s a young, up-and-coming rock star in the medical world.  (He’s in his early 40’s, which by surgeon standards, is young). 

I think we are intrigued because he’s intelligent, well-spoken, friendly, handsome and has a shock full of black hair (most surgeons are either bald or graying by forty).   Med student guys want to be like him, med student ladies want to marry him.  Well, something like that…

And then the writers admire him too for his eloquence — he was a finalist for the National Book Award.  Today, he was here to promote his new book, Better, which is on medical performance and errors.  After his lecture, there was a huge line of eager students waiting to get their copy of Better signed.  I felt like such a groupie as I waited in line to ask him a few questions about one of his papers called “Risk factors for retained instruments and sponges after surgery,” published in the New England Journal of Medicine (NEJM 2003 Jan 16;348(3):229-35).  

In this study, his team looked at several hundred cases of surgeries and tried to figure out how in the world doctors could do something as “stupid” as leave a sponge in a patient’s body.  It’s one of those things that you probably have heard about and would make you shake your head in disbelief.  I wanted to post a Youtube video on this topic, but because of the potential explosiveness of the issue (i.e., I didn’t want to my surgical professors to fail me for getting it wrong) I thought it best to double-check.

Dr. Gawande was gracious, answering my questions while signing books at the same time.  He pointed out, “it’s not for lack of trying.”  The surgical team hand counts the instruments and double-check, triple-check all the time to avoid this error, and it doesn’t happen often.  But the problem is that, when it happens, the consequences can be life-threatening.  Plus, the surgeons who do so feel terrible and the media makes them look–well, stupid.

The point that progressive healthcare policy experts — such as Dr. Gawande and Dr. Don Berwick — are trying to make is that, often, the error is not caused by ‘stupidity’ and ‘clumsiness.’  Instead, it’s the problem of the structure of the healthcare delivery system.  Perhaps, doctors are overworked, hospitals understaffed, budgets are cut (to name a few possible reasons).  Nobody tries to be clumsy — most doctors are trying their hardest not to be.  The solution ought not to be blame, but rather to find out why the errors are happening.  Often, the answers are simple (and that’s why I hope to post up a lot of them in this blog, so that you can share with your family and friends easy, but powerful tips).

Dr. Gawande points out three risk factors that can explain in large part why doctors leave tools in the patient’s body.  The first one is if the patient is obese — it can be tricky to perform surgery on someone who has a high body mass index.  The second is when there is an emergency procedure that needs to be done — as you can imagine from the frantic scenes you’ve seen on ER, it’s tough to keep track of everything.  The last factor is when there is a change in the surgical procedure; for example, if the surgeons originally thought they were going in to remove the appendix but found a surprising cancer instead. 

The solution to prevent tools getting left inside the body is simple: take an X-ray before the patient wakes up from recovery — if there’s anything left in the body, you just quickly take it out before it causes any harm.  It’s simple, almost common-sensical — but unfortunately, not enough surgical teams are making it common practice.

So please keep this in mind if you or your family friend needs surgery.  And if your doctor has any questions, you can pull up Dr. Gawande’s article and show it to them – if you need a copy e-mail me and I can help you find one.

Best wishes!


April 26, 2007 - Posted by | Health news, Surgery | , , ,


  1. Thank you for your interesting post!
    I thought perhaps you may find this related post about new article by Atul Gawande interesting to you:
    Longevity Science: The Way We Age

    Comment by Longevity Science | April 29, 2007 | Reply

  2. How’s your second year experience progressing?


    Comment by Kia | February 10, 2008 | Reply

  3. Great post! I’ve heard that there are also major problems from sponges getting left in as they blend in easy once filled with blood and stick together when wet so there hard to count. would an x-ray be able to pick up a misplaced sponge? thanks a lot for the post!

    Comment by Perry | February 20, 2008 | Reply

  4. I can tell that this is not the first time at all that you mention the topic. Why have you chosen it again?

    Comment by Samuel L. | April 24, 2009 | Reply

  5. I would just like to say that it is not as simple as just taking an x-ray and removing the sponge or whatever is left behind. I am a studying to be a surgical technician and its tough when we are doing our final counts because the surgeon is already closing the patient up as we are counting. You need to understand that the surgeons need to close the patient as soon as possible because of the many risks of being under anesthesia for too long or being in a certain position for too long, especially if the patient is elderly or an infant. So between the rush of closing the patient and the rush of trying to get your counts done before the patient is closed up it is possible that something can get left behind. I’m not by any means saying it is ok for this to happen, I’m just simply saying that it does happen.

    Comment by Ang | March 27, 2010 | Reply

    • Why would you even consider giving a surgeon a suture in the first place until you’ve done a count?? There’s a higher risk of the patient being compromised with retained items than a few extra minutes of anaesthesia.You need to understand that the surgeons DO NOT have to close the patient “as soon as possible” if it means the slightest chance that something may still be inside, only then having to face yet another anaesthetic to remove the retained item. A scrub/instrument nurse should know exactly where every item is at all times anyway then as soon as the surgeon asks for the closing suture the scrub/instrument nurse is able to say ‘I can’t account for one of my sponges.” It’s even tougher for a surgeon to close a patient without a suture and you should not be giving him that suture until you’ve done the count.
      You are the patients advocate.

      Comment by rocme | May 19, 2010 | Reply

  6. […] A Medical Student Blog: A third year med student blogs about his interest in all things medical. […]

    Pingback by 42 Medical Blogs Written Entirely by Med Students | Medical Insurance | May 28, 2010 | Reply

  7. Just read your article. I most say I desagree. I am a scrub techinician for 25 years now. The problem of surgical objets left inside patients is a matter of no following the universal precautions how is written in text books. The procedure is as follow: Once the Surgeon is done all laparatomy sponges, retrators, and surgical instruments. Surgeon start closing the peritoneum. At this point I iniciate the count of laparatomy sponges first because those are the one use in the abdomen freely. Small sponges like 4×4 or 4×8 should be use in the abdomen with a sponge stick, not freely. After that I count instrumentations. At this point I can assure the Surgeon that I can continue closing the wound. This process takes about 2 to 3 minutes if the Scrub person is organized and as mantained an orderly field during the surgery. All instruments are back on the table. The only instrumentation on the mayo stand is the instruments the Surgeon is using to close the wound. After Surgeon finished closing peritonium, he proceed to close fascia. At this point the cavity of close and instruments are miminum on the fiel. We he start closing skin I proceed to do the final count of sponges needles, and other small items. I have to have the same amounts of instruments and surgical items that I started the surgery with. Size of the patients does not matter. A correct count is a effort of the Surgeon and the Surgical Team to assure that nothing was left behind. Even is the hospital do not have a good protocol, Medical professional suppose to be train in Universal Precautions. The problem today, is the lack of attention, organization and education we are seeing in the Medical Field.

    I hope this help to see the sad reality of what is going on today in the Medical field.

    Another problem is that hospitals a running their practices with short staff and are pushing the Surgeon to work faster because of short staff. They give them a block time with a time estimate and that does not work very well, we can see the results. Mayor hospitals use to work 24-7 in the old days. Patient care was a priority. Today is production the priority. Very sad.


    Comment by Lizette | February 26, 2011 | Reply

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