Complications can last a lifetime
Consider the case of an Ohio woman who underwent gastric bypass
surgery in the spring of 2012. Following surgery, her initial complaints
of abdominal pain and constipation after surgery were attributed to
recovery and given little attention by providers. Over the course of the
next 18 months, her pain became excruciating, her weight loss left her
looking "wasted" and her intractable vomiting developed a fecal odor.
Frustrated with her surgeon's failure to address her complaints, she
went to a different hospital for evaluation.
The emergency department physician she visited immediately
ordered a CT scan. The images showed a surgical towel, left behind
after her surgery, imbedded and twisted around her intestines. She
underwent multiple surgeries in an attempt to fix a perforated area
and surrounding infection caused by the towel. She spent several
weeks in a medically induced coma, but eventually passed away from
the overwhelming complications.
A medical malpractice suit was filed, and attorneys took depositions
from the OR nurses. According to the medical record, a correct count
was taken 3 times during the surgery. When the OR nurses were
asked to explain the discrepancy, only 1 provided a possible explana-
tion. He suggested the possibility that 2 towels had mistakenly been
packaged as 1 and were counted as a single item at the onset of sur-
gery. He theorized that when the combined towel became saturated it
separated into 2 pieces, one of which was left behind while the other
was counted upon closing.
Staff must remain hyper-vigilant about preventing retained objects.
It's not enough to do a count at the beginning and end of the proce-
dure. While the monetary costs associated with retained instruments
are calculable, the effect on the patient is immeasurable. Here's what
more we can do.
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