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Surgically Retained Instruments and the Onset of Electronic Tracking Technology

December 06, 2012

While working a night shift back in 2005, Sophia Savage, a 59-year-old nurse in Kentucky, began to experience a severe “crushing” like pain in her abdominal region that caused her to become violently ill. Having no idea what the source of the problem was, Savage decided to undergo a CT scan, which revealed that a surgical instrument had been lodged in her abdominal cavity.

It turned out that the surgeon who performed her hysterectomy four years earlier had left behind a surgical sponge. Savage required immediate exploratory surgery to locate and remove the object.

According to Ms. Savage, what the subsequent surgery revealed was “horrific,” as the sponge was found lodged to her bladder, stomach area, and the walls of her abdomen. Moreover, the sponge also caused a major infection to spread throughout Ms. Savage’s body, requiring surgeons to remove a large portion of her intestinal tract. Ms. Savage subsequently filed a lawsuit against the hospital where her hysterectomy was performed and was ultimately awarded $2.5 million in compensation for her extensive injuries. However, the hospital appealed the award, which since then has caused her to suffer from severe anxiety and depression. Ms. Savage also continues to face debilitating bowel problems and as a result, has been unable to work.

In the United States, an estimated 4,000 cases occur each year that mirror the facts of Ms. Savage’s case. According to nationwide medical reports, it isn’t uncommon for surgical sponges, used to soak up excess blood, to be left in a patient’s body, especially after undergoing a long operation. While hospitals generally require surgical teams to account for all surgical instruments and objects, this is usually done the old fashioned way by nurses who count and recount the number of objects that are retrieved during surgery. However, counting mistakes happen, especially when things become fast paced and chaotic in the operating room.

Alarmingly, studies indicate that in 80% of cases where surgical tools are left behind, the surgical staff purportedly accounted for all of them. Studies also provide that patients who undergo abdominal procedures, especially those who are overweight, are most vulnerable to having objects such as surgical sponges left behind. There have been incidents where doctors leave all types of surgical instruments behind in patients, such as scalpels, clamps, and occasionally, scissors. However, the vast majority of all surgically retained items are sponges, which are often hard to detect after being camouflaged by body tissue and blood.

Recently, new technology and more revolutionary methods to account for surgical tools have offered some hope in remedying the problem. According to a major study published in the Journal of the American College of Surgeons, researchers analyzed over 2,200 cases of surgeons who used a technology called the RF Assure system, which injects tiny “rice sized” radio frequency tracking devices into surgical sponges. Over an eleven month period, these tracking devices were able to detect and recover over 23 sponges that would have been left behind in patients but for the new technology.

Another type of tracking system that has also received positive attention is one that relies upon bar code technology. To illustrate, every sponge is assigned a bar code and gets scanned before and after use. This allows for medical staff to electronically account for all instruments and objects that are used during surgical procedures.

Despite the ingenuity of electronic tracking systems, less than one percent of hospitals have adopted these types of technologically advanced methods. Specifically, doctors using the RF Assure system and other electronic tracking methods generally praise the technology; however, numerous hospitals, perhaps due to cost, continue to refuse to implement these types of patient safety enhancement procedures. Hence, hundreds of thousands of patients continue to be at risk.

Many doctors have become strong advocates for electronic tracking, noting that it can provide a significant and inexpensive safety net when traditional counting methods fail. However, others posit that the technology should only be used to supplement manual counting methods and that all surgical team members, not just nurses, should bear responsibility in accounting for surgical instruments. While numerous medical professionals believe that tracking technology is certainly helpful, many still feel that cultural changes in the O.R. will greatly reduce the overall occurrence of surgical counting errors.

If you or someone you love has been injured or a loved one has died because of mistakes by a medical professional, our experienced Gerogia medical malpractice attorneys provide compassionate and diligent legal representation to our clients. We invite you to contact Montlick and Associates now for a FREE CONSULTATION with our experienced Georgia medical malpractice lawyers, and will even travel to meet with you if needed. Call us at 1-800-LAW-NEED (1-800-529-6333) 24 hours a day/7 days a week for a FREE CONSULTATION or visit us online at for our 24-hour live online chat service or FREE CASE EVALUATION FORM.

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