Surgical Tools Left Inside Patients

Researchers have conducted a study on surgical instruments and sponges forgotten in patients in an effort to learn how to prevent this potentially dangerous problem. Their study was published in the January 16, 2003, issue of The New England Journal of Medicine.

The investigators estimate that surgical tools are left inside a patient in the United States at least 1,500 times per year. However, this is only a fraction of the more than 28 million operations performed each year. So while it is not a common error, the researchers say it can be dangerous. Retained instruments can result in severe infection, damage to organs, and perhaps even death. One patient cited in the study had had a forgotten clamp removed from his body only to find several years later that another six-inch metal clamp was still in his body from the initial operation.

One goal of the study was to find what factors determined whether or not tools got left inside a patient. The investigators, from Brigham and Women's Hospital (Boston, USA), studied records from a malpractice insurer. From these they learned that around half of retained instruments were found in the abdomen, 22% in the vagina, about 7% in the chest, and 17% in other places, including the face, brain, spinal canal, and extremities.

Patients with tools left inside them were nine times as likely to have undergone emergency surgery as other patients and four times as likely to have experienced an unanticipated change in the procedure. Both emergency surgery and a change in the procedure could have resulted in disorganization, making it more difficult to keep track of tools. Another important factor was size. Heavy people were found to be more likely to have tools left in them, probably because they offer more room for losing objects.

The authors suggest that surgical teams count sponges before and after every operation and count instruments each time surgery involves an open cavity. Another solution they recommend, especially for high-risk situations such as emergency surgery, is to take x-rays in the operating room right before the patient is sewn up, to look for forgotten objects.




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Brigham and Women's Hospital