Gibbs’ work with sponge detection systems revealed a surprisingly low-tech solution in what looks like a blue plastic bag with clear slots one might hang shoes in on the back of a door. Instead of shoes, the bags hold used and unused sponges in groups of 10 that are easily accounted for at the end of the case.
Gibbs and Harder emphasize that preventing RSIs isn’t just about avoiding the actual forgotten object being left inside a patient. It’s also about preventing the chaos, wasted time, x-rays, panic, and annoyance that pervade the surgical theater when a miscount occurs.
The team tears apart the room, searches behind the drapes, and gives each other side-glances while the clock is ticking for the anesthetized patient and the next operative case waits outside.
But fixing the problem of miscount has not been a top priority at many hospitals, Gibbs says. That’s because teams don’t get it and the C-suite doesn’t become engaged until an actual case of a retained sponge occurs, she says. “If they have one event, they say, ‘We had one event.’ They don’t jump up and down. Then they have another retained sponge, maybe a year later.”
The fact is, many cases are never litigated; if they are, they’re settled, and if they go to court, verdicts run around $50,000 to $100,000, Gibbs says, which isn’t enough to prompt a hospital to buy in to a major systemwide fix.
Then they get the third case. “That’s when they call me up and say ‘We have a problem’ and ask for advice.”
Someday, creative thinkers may figure out a dependable technological means to account for all these items in an unobtrusive, cost-effective, and reliable way. But until that day comes, the change has to come in the culture, Gibbs says.
“That’s why all this new technology stuff is not going to be the answer,” Gibbs says. “The answer is working with doctors, nurses, anesthesiologists, and radiologists—to work together to make sure we don’t leave our surgical tools in patients.”