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!