Why do hospital teams unintentionally leave more than 30 types of surgical tools or other items inside their patients, a category of hospital error that California officials say is the second most common preventable adverse event in acute care?
And why does the number of these forgotten items continue to increase?
State health officials want to find out and propose using $800,000 in administrative penalties collected from hospitals since 2007 for a collaborative project to study the problem.
"The public at large keeps asking, 'how can this keep happening?'" says Kathleen Billingsley, deputy director for the state Department of Public Health. "We see ourselves as having a great opportunity to conduct this statewide initiative to share best practices, and hopefully reduce the rate of retained foreign objects in patients not just in California, but in other states as well."
Billingsley says inadvertently retained foreign objects, including catheters, a denture, drill bits, electrodes, sponges, screws, tubing, tissue specimens, and wires, account for 18.6% of all adverse events reported by the roughly 450 California hospitals that perform invasive procedures.
Time-outs, pre- and post-surgery foreign object counts, double and triple staff repeat counts and checks, precision-count packaging, X-ray labeling, and other measures still fail to put a dent in the number of surgical teams that repeat the same mistakes.
For example, for fiscal year 2007-08, state health officials counted 141 retained foreign objects in patients. For the next fiscal year, 2008-09, the count was 196. And in the first 70 days of the 2010 fiscal year, between July 1 to Sept. 8, 2009, 45 foreign objects have been reported. At this pace, by end of this fiscal year, the number of mistakenly left objects will number 225.
According to state documents submitted by Billingsley's staff to the state Legislature, the "High-Risk Operating Room Department Safety Collaborative" is designed "to assist hospitals in developing a culture of safety and improving communication with the operating room, with the intent to reduce or eliminate adverse events."
The proposal notes that a report by Thomas J. Krizek, MD, of the University of South Florida, found that "as many as 45% of all surgery patients had one or more adverse events and that over 20% had events considered serious and either limb or life-threatening.
"The study also found that surgery patients who experienced no adverse event had an average hospital stay of eight days, whereas patients with an adverse event had an average stay of over 23 days and those with a serious adverse event had a stay of 32 days."