A new study has compared what happened to cause that mishap in 54 surgeries. They found certain factors were more common in cases where instruments were left behind. Those cases likely involved some emergency rather than routine surgeries. Or the patient was very large. That, despite strict regulations designed to prevent problems like that.
"You have a patient come into the operating room and the proper procedure is two nurses have to count everything twice at the beginning and then at the end to see if the counts match. If they match, you assume everything was accounted for. Well, you have someone bleeding and you rush them to the operating room, the priority is get them open and get them taken care of and so the nurses have to count very quickly and things can be much more disorganized and those are situations where an error can occur," says Dr. Atul Gawande, Surgeon and lead author.
Of the 54-patients studied, 33% had emergency surgery, 34% had an unexpected change in the surgical procedure and these patients had a higher average body mass index compared to patients with no complications. The study involved a variety of surgical procedures with instruments being left behind in the abdomen, brain, throat and vagina. The instrument was most often a sponge and was usually discovered within 21 days of surgery. 37% of the patients required reoperation for the removal of the object and to manage complications. In one case, the instrument left behind resulted in the patient's death.
Experts estimate instruments are left behind in 1 out of 19,000 patients. This study was conducted by researchers at Brigham and Women's Hospital and Harvard School of Public Health. It is published in the New England Journal of Medicine.