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Our last two posts have talked about the prevalence of preventable errors health care workers make. Preventable errors range in severity, and include mistakes such as operating on the wrong body part, operating on the wrong patient, amputating the wrong limb and leaving surgical instruments in the body after an operation.
The errors are so egregious that it’s difficult to believe that doctors and nurses in Pennsylvania and throughout the country make those types of medical errors daily. Thankfully, one hospital created a simple new protocol to help ensure no surgical sponges are left behind when surgery is complete.
One statistic suggested that a surgical sponge is left in a patient during one in 6,000 surgeries. The threatened risk may not be high, but it’s still too large of a percentage when the mistake is 100 percent avoidable. Moreover, the consequences of a sponge that is left in a patient’s body can be severe.
In 2009, the Mayo Clinic implemented new technology to help avoid leaving sponges in patients’ bodies. The new technology is basic — a bar code reader. However, when it is used correctly, it can reduce the potential for human error.
During any given surgery, a package of sponges is used on a patient. The package comes with a barcode, which is scanned at the beginning of the procedure. Each of the sponges also has an individual bar code, and each sponge is scanned at the end of the procedure to help ensure they’re all accounted for. Surgeons or nurses also manually count the sponges after procedures, which has always been the policy.
One surgeon who performs ear, nose and throat surgeries was initially reluctant to the new technology. She said, “What concerned me the most was that it would take up a bunch of extra time when they’re scanning them. And it really doesn’t.”
Since the new technology was implemented at one Mayo hospital in 2009 there has not been a single sponge left in a patient, and the additional time it takes to use scan the bar codes is negligible. Finally, as with any new operation, the cost must be considered. The bar code system works out to about $2 per operation.
If the technology is so efficient and affordable, why aren’t more hospitals jumping on board to implement bar code scanning to reduce the number of sponges that get left behind?
Source: The Free Press, “Bar coding sponges safeguards against surgery mishaps,” Robb Murray, March 16, 2012