That's why one system for tracking and locating "retained objects"—things left in patients after an operation—is getting a closer look in the medical community.
Manufactured by RF Surgical Systems of Bellevue, Wash., the RF Surgical Detection System uses a scanning wand to find any tagged items remaining in a patient. Tags (or seeds) about the size of a rice grain are imbedded in gauze, sponges and the like. One wave of the wand over the patient will reveal if the coast is clear.
A retained item can cause a blockage or other problems, even death.
"Nurses count everything that goes into the patients—sponges, gauze, instruments, sharps—and they count everything that comes out," said Kevin Cosens, chief executive of RF Surgical Systems. "If the counts don't match, then, of course, they can't close the patient."
That means a recount, making a pile of bloody sponges and gauze, going through garbage cans.
How Often Does This Happen?
There is no definitive data on the frequency of retained objects. According to the New England Journal of Medicine researchers, "The incidence we found of 1 in 8,801 to 1 in 18,760 inpatient operations corresponds to one case or more each year for a typical, large hospital." Because the study was based on malpractice claims, those numbers were most likely underestimates, researchers said. And Cosens said that numbers from Minnesota, which reports all surgical errors, indicate there is a retained object in 1 in 8,000 surgeries.
Sponges (the most common retained object) and other items get left behind for various reasons. There can be a human error. There are supposed to be 10 sponges in each package; maybe a pack has only nine. In an emergency situation, an extra item may get tossed into the mix.
"With this system, if that should ever happen and the count still comes out correct, you still are able to wand the patient," said Kim Stache, administrative director of surgical services at Edward Hospital in Naperville, Ill., which started using the system in December.
"Because of the RF seed, if there is still a sponge in the body or the opening, it would beep at us to let us know, hey, there's still something in the wound. Whereas if the counts were correct, the patient would be closed. And if complications arise later, you find that the sponge was left behind. In the large majority (of cases) of sponges left behind, the counts were correct."
Does the System Work?
More than 100 hospitals are using the system, Cosens said, which adds the extra layer of security at a cost of about $15 per surgery.
"We've had zero retained objects in all of the hospitals that are using our system over the last two years," Cosens said. "We're getting a lot of positive feedback."