It is one of those stories that sends shivers up and down our spines. Next to operating on the wrong patient or the wrong body part, leaving surgical “stuff” inside a patient’s body tops our list of “never events.” These are things that are NEVER supposed to happen during surgery. In theory, surgeons and their assistants are supposed to check for sponges and other equipment before closing. Sometimes, though, there are serious mistakes!
What Got Left Behind?
The latest story of an incredible screw-up that should never have happened apparently involves a German patient named Dirk Schroeder. According to reports from Europe, Mr. Schroeder, 74, underwent what was supposed to have been “routine surgery” for prostate cancer.
After the surgery, however, he experienced significant discomfort. The pain was such that he had difficulty sitting down. In some accounts it was described as “appalling agony.”
In Germany, nurses often make home visits to follow up on senior citizens in distress. During just such a visit a nurse discovered a large gauze pad protruding from the surgical wound. Subsequently, he went back to the hospital for exploratory surgery to see what was going on.
16 Items Left Behind…Really!
During two separate operations surgeons allegedly removed 16 items including a needle, cotton swabs, a 6-inch bandage roll, a 6-inch compress, a piece of a surgical mask and goodness knows what else.
One has to wonder what happened during the original prostate surgery that could have led to such oversight. Were these surgeons and nurses partying at the patient’s expense? Who was counting swabs? Was anyone paying attention?
The Hospital’s Explanation Defies Imagination:
But wait…it get’s stranger. The hospital’s response was that all these surgical “left-overs” somehow entered the patient’s body AFTER the surgery was completed and the wound closed. Huh? How exactly did this stuff wander from the outside to the inside of Mr. Schroeder’s body after the surgery was complete?
Guess how much the hospital offered the family to settle the case? (Mr. Schroeder died last year.) According to the family lawyer, the hospital initially offered $660 to get the family to go away and stop complaining. We’re not surprised they didn’t agree to this settlement. The family was reportedly asking for $127,000 in damages.
Surgical Errors in the U.S.
In the U.S. few, if any, malpractice attorneys would take on such a case for a sum of that size. The expense to bring such a lawsuit to trial could cost nearly that much and wouldn’t be worth a lawyer’s time.
We thought this case was worthy of your attention because it reinforces a study published in the journal Surgery (online Dec. 17, 2012) titled “Surgical Never Events in the United States.” The investigators from Johns Hopkins estimated that 40 times every week in the U.S. sponges, swabs or other “stuff” is left behind in a patient after surgery. To read more about this debacle, click on this link.
Stories from Readers:
Here are some comments from visitors to our website about their surgical experiences:
C.M. had problems with the anesthesia:
“I had a back operation recently and as a result of the anesthesia, I had hallucinations afterward.
“It took me a month to get my brain back to normal. I would ask for a ‘cup of coffee’ and it would come out as ‘a cup of carrots.’“I thought is was just me but I have talked to people since and they have told similar stories. What are they using in anesthesia now a days?”
J.S. also reports on post-surgical problems with family members:
“Both my grandfather and my father had hallucinations after surgery, whether due to anesthesia or pain meds, I don’t know. We had to have someone stay with them round the clock.
“My grandfather suffered a broken cheekbone trying to get out of bed, swearing he was being attacked. My dad ripped out his catheter and attacked a nurse. Neither one of them was violent when in their right minds.
“Fortunately, they both returned to normal after they were off the meds and back home. Even being prepared, as we were after the first incident, it was awful to watch a loved one go through that.
“My dad had hallucinations in hospice as well, due to Ativan. We requested no more Ativan, and the hospice doctor told us sometimes we had to do things we didn’t want to do. I asked him point blank away from my mom, and he said, yes, they were still giving dad Ativan, despite dad’s and our wishes.
“Fortunately, it was put in his chart, and the nurses refused to give it. Dad was able to spend much more coherent time with us than the doctor expected, thanks to those nurses.”
Donna experienced long-term consequences:
“During a hysterectomy in ’04, the doc ‘accidentally nipped a vessel’ and I lost a lot of blood and needed massive transfusions. The doctor told me this when he came in after the surgery to speak to my husband and me. As a result of the blood loss, I experienced permanent vision loss when the optic nerve in my left eye collapsed, and severe anemia for weeks afterward.
“A year or so later I began to experience chronic urinary tract infections [UTIs] which I’d never had a problem with at all before. In ’08, after many courses of antibiotics for UTIs, a urologist looked into my bladder and found what appeared to be three growths. He operated to biopsy and/or remove the ‘tumors’ but instead found 3 metal staples embedded in the bladder wall.
“They’d been collecting bacteria and were pretty gross. The urologist/surgeon removed them and I became symptom free — no UTIs for a while. The staples must’ve been left by the gyno surgeon in ’04.
“This Nov. after another couple of years of UTI’s and many more courses of antibiotics, I passed a stone after much vaginal bleeding. The urologist again found a metal staple had apparently migrated to my bladder wall, and a stone had formed in my bladder.
” I know that my records from the gyno surgeon do not mention the nipped vessel, the blood loss, vision loss or anemia. I also got a copy of the surgeon’s notes since I’d been told that everyone in the operating room during my surgery had to sign off on those notes, so they would contain all that happened — and they did not tell all, although everyone apparently did sign off on them.
“Once again I’m now symptom free in terms of UTIs, however I have no idea how many more staples I have inside — or where they are…
“The total lack of accountability makes me mad/sick. How can this surgeon continue to practice and never acknowledge his mistake. How many more mistakes has he been allowed to make with no consequences?”
Preventing Medical Mistakes:
It doesn’t have to be this way. The Agency for Healthcare Research and Quality (AHRQ) reported the results of a study in the New England Journal of Medicine. This research evaluated the benefit of checklists during surgical crises. We’re talking about such events as the one Donna describes above, ie, a severe bleeding episode.
Other such events include cardiac arrest [when the heart stops beating regularly] or a life-threatening allergic reaction. In the middle of a surgical emergency some health professionals may panic or forget proper procedures.
Checklists Work!
In this randomized controlled trial the researchers created a number of simulated crises. In some cases the OR teams followed a checklist while in other situations they tried to do the right thing based on their instincts or memories. When the teams used a checklist they were 75% less likely to delay or miss a life-saving step.
Most revealing of all, after participating in this experiment 97% of the health professionals involved admitted that if they themselves needed surgery sometime in the future they wanted the OR team to employ a checklist if something bad happened. That seals the deal for us!
Protect Yourself From Medical Errors
Next time you have to have surgery, you might ask the surgeon, anesthesiologist and any other members of the team if they could employ a surgical checklist if anything goes wrong during the surgery. Ask if they would consider reviewing the New England Journal of Medicine article before your procedure so that they would know more about the benefits of such a checklist. Any physician with access to The New England Journal of Medicine (and that should be all doctors) can find the “Crisis Checklist” in the Supplementary Appendix to the online article. It should be kept in readily accessible places in the OR!
Images of instruments left behind by surgeons can be found at this link.
Have you ever experienced a medical misadventure? How did you handle it? Would you like to learn more about how to avoid mistakes in the hospital or in the doctor’s office?
You will find our top questions to ask your doctor before agreeing to surgery on page 177 of our book, Top Screwups Doctors Make and How to Avoid Them. You will also learn about the Top 10 Tips to Stopping Screwups in Hospitals and the Top 10 Questions to Ask to Reduce Diagnostic Disasters. Here is a link to the paperback edition of our book.
We hope this book will reduce not only hospital errors but many medication mistakes. Take a moment to read the reviews by readers to see why this book might save your life or the life of someone you love.
How To Prevent Surgical Mistakes:
Do you think you would be brave enough to mention a crisis checklist to your surgeon before an operation?
Have you ever experienced a surgical misadventure? What about a medication mistake?
We would like to hear your answer to our question or your story below. Please comment and let others benefit from your experience.
Revised 4/5/18
