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Technology aims to prevent surgical never events

There are a certain category of surgical errors that the health care industry considers “never events,” which means, quite simply, that they should never happen. Unfortunately, that is not the case. One example of this is when surgeons or surgical assistants accidentally leave sponges and other medical equipment inside a patient’s body. Despite being labeled as a never event, sponges are left inside patients’ bodies fairly often. But because there is no comprehensive system for tracking these errors in the U.S., the exact rate of occurrence is not entirely known.

In one three-year study, the Mayo Clinic found that the rate of “retained foreign objects” was about one in every 5,000 surgeries. Another study, which looked at 20 years of medical malpractice settlements, found that this particular type of never event occurred approximately five times per day, with an estimated 2,024 claims every year.

Regardless of the specific numbers, it is widely agreed-upon that foreign objects should never be left in patients after surgery, and that more needs to be done to prevent these potentially-fatal surgical errors. Recently, a large medical device manufacturer purchased a smaller company that makes surgical sponges with bar codes that can be read by electrical counters even when they are soaked in blood or other fluids. Other companies are also manufacturing similar high-tech sponges.

Although those technological advances are significant steps toward the elimination of this particular never event, the medical industry could – and should – do more to prevent it. Better tracking of errors, a commitment from leadership and the ability and willingness of employees to report unsafe conditions are all essential for patient health and safety.

Source: Bloomberg Businessweek, “Can Technology Stop Surgeons From Leaving Sponges Inside Patients?” John Tozzi, March 25, 2014

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