Leaving a surgery sponge (gossypiboma) or other foreign object in a patient’s body can cause serious complications or even death. According to Medicare data, there were 750 such cases in 2007, which cost an average of $63,631 per hospital stay. That’s more than $47 million a year, and does not include potential legal costs associated with such events.
We can examine the problem of post-surgery foreign object retention by putting it into a visual root cause analysis (or Cause Map). A foreign body may be left inside a patient if it is not visible in their body, is not detected by radiography, and is not recognized as missing. We continue to ask why questions to fill out our root cause analysis.
Why would the object not be detected by radiography? The object may not be detectable by radiography, as some sponges are not. The object might not be noticed in the radiography, if the person reading it is not adequately trained, or if there is no double-check. Or, radiography might not have been used. This is contrary to some organization’s recommended procedures.
How would the object not be recognized as missing? The instrument/sponge count may be inaccurate, or it may not have been done at all, which is also contrary to recommended procedure.
Since we have “Did not follow procedure”, we need to outline what the proper procedure should be. We call this a “Process Map”. Here we show the procedure for instrument and sponge removal verification. Instruments and sponges are counted before, and twice after surgery. If the count does not match, there is a physical re-examination, and radiograph to determine whether the object has been left inside the patient. Different organizations may use a slightly different process, but what is important is that it is formalized and examined in the case of any incidents, such as a left-behind sponge or instrument.
Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map made with our root cause analysis template.
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