Study finds that objects left inside patients a rare problem

Health » Hospitals pledge to figure out why and how to fix it.
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Utah hospitals continue to mistakenly leave equipment such as sponges inside patients -- many of them women undergoing obstetrical or gynecological surgeries, according to data released Wednesday.

It rarely happens, but remains a problem: Such foreign objects were left 25 times last year out of more than 200,000 surgeries.

The information was released by the state health department and the state hospital association to coincide with National Patient Safety Awareness Week.

The annual report is on "sentinel events" -- unexpected incidents resulting in death or serious physical or psychological injury. The problems can be caused by a range of events, including surgical mistakes, medication errors, falls and crimes.

Hospitals must report the injuries to the Utah Department of Health, though the names of the facilities cannot be publicly released. The goal is to identify and fix system-wide problems.

"Where we need to focus our efforts is on the surgical events," said Iona Thraen, patient safety director for the health department.

That's because out of 101 sentinel events reported in 2009 -- up from 80 reported in 2008 -- 58 were related to surgery. That could include performing the wrong surgery on the wrong patient, death during surgery and retention of foreign objects.

No specifics were provided on the type of objects retained, though the report said "many" happened to ob/gyn patients.

Hospitals first started reporting foreign-object injuries in 2008. With two years of data showing it is a problem, "Now it's time we figure out what we're going to do about it," Thraen said.

Hospitals have pledged to "drill down" to figure out why the foreign objects aren't removed and how to solve the problem.

"If I were to give you a wad of bills that are wet and soggy and full of blood, and tell you there are 371s bill and you have to count those out, how many times would you have to recount them?" she explained. "That's the surgical count issue."

This year is the first time hospitals have participated with the Utah Department of Health in releasing the data. In the past two years, it was released after a request by The Salt Lake Tribune .

This year's report provides less data. The 2007 and 2008 reports included the number of patients who died, along with the number of patients injured by falls, medication errors and crimes. Thraen said she does not intend to release those specifics this year. The Tribune is requesting it through the open records law.

"We're trying to focus on improvement and not react to the hysteria that is the response to seeing these things [in the media]," she said.

By the numbers Major medical injuries, Utah 2009

Of 101 sentinel events -- defined as unexpected deaths or major physical or psychological injuries -- reported by hospitals and surgical centers:

58 were surgical, which could include death during surgery, wrong-site surgeries and retention of foreign objects.

18 were related to care management, which could include medication errors, administration of the wrong blood product, unanticipated death of a full-term newborn, maternal death or injury during labor or delivery and serious ulcers.

12 were "environmental," which could include falls, electric shocks and burns.

9 were "patient protection," which could include infants discharged to the wrong person, suicides or patient disappearances.

3 were product events, which could include the use of contaminated drugs or devices or air embolisms in the blood stream.

1 was criminal, which could include assault, patient abduction, impersonation of medical personnel or non-consensual sexual contact.