Now Where Did I Leave That Sponge?


A short time ago, the Chicago Tribune ran a very interesting story on the use of bar codes as well as Radio Frequency (RF) detection as a means to keep track of surgical sponges during operations. Sponges are left in about 1,500 people a year during their operations in the US. In a 2003 study published by the New England Journal of Medicine, leaving sponges and other surgical instruments in patients happens most often during emergency surgery or because of some unexpected change in the surgical procedure.

One system by SurgiCount uses a bar-coding approach. "Essentially, the system works much like a grocery store check-out counter â'' every laparotomy and gauze sponge is pre-labeled with an individual and unique bar code and a scanning SurgiCounter is used to read the labels.

"When using the system, staff concurrently scan sponges during their manual counts or can scan the items before or after the manual count. The SurgiCounters can be held by the circulator, or can be placed on a holster on an IV pole in a hands-free mode. By scanning in the unique labels, the system builds a database of items used in that particular procedure. At the end of the procedure when the circulator is counting out the sponges, the circulator will again swipe the sponge under the SurgiCounter, this time in order to 'count' the sponge out of the database. Because each sponge has a unique bar code, the system automatically alerts the staff in case they have accidentally tried to count the same sponge twice. This assists the staff in validating that they have an accurate count in case the there was a manual counting error."

Another approach is that developed by Medline called RF-Detect. Here, "a sterile radio frequency chip, (the size of a grain of rice) is embedded in the surgical disposables. With the RF Detect system, a Blair-Port wand is waved over the patient accurately alerting the user when an RF-tagged surgical disposable remains in the patient before surgical closing procedures."

Of course, it isn't only surgical sponges, towels or surgical gauze that is left in patients. A 2003 story involving the New England Journal of Medicine study that I mentioned above in the New York Times describes a patient who had a six inch metal clamp left in him. This was left as a result of a previous operation to remove a previously lost metal clamp. Talk about being unlucky.

In a BBC story from 2005, a man left the hospital with a two inch scalpel blade in him after heart by-pass surgery, which wasn't found until months later by an x-ray for a different condition.

Hospitals are working harder to ensure that these types of medical "never events" don't occur, not only because of the patient's health and the cost of lawsuits, but both Medicare and insurance companies like Aetna and Wellpoint are now refusing to pay for fixing these problems.


Risk Factor

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Robert Charette
Spotsylvania, Va.
Willie D. Jones
New York City