It might be called a hospital’s “quadruple jeopardy”: A hospital can be penalized four ways when a surgical item—most likely a sponge or lap pad, but increasingly a detached piece of metal or plastic—is unintentionally left inside a patient.
Two financial penalties will be assessed facilities that forget to remove surgical implements from Medicare patients, according to two separate sections of the Patient Protection and Affordable Care Act. And since October 2008, Medicare won’t pay hospitals for additional care necessitated by forgotten sponges
The fourth jeopardy came in April when CMS publicly released the names of hospitals where retained surgical items were left in patients.
Of course, the patient safety movement has given this effort a very big push. And a number of companies are developing technical solutions that use matrix labels similar to store bar codes, radiofrequency tags or computer chips, special wands to wave over or scan the patient after surgery, and gel pads for the table that sound an alarm if a tagged sponge is left inside a patient.
“But all of them have problems; there’s no ideal system, despite the fact that lots of companies are saying theirs is the best. No one is the best,” says Verna Gibbs, MD, chair of the San Francisco VA Medical Center Surgical Service Quality Improvement Committee and director of the No Thing Left Behind project.
She and Kathleen Harder, PhD, a cognitive psychologist who directs the Center for Design in Health at the University of Minnesota, say the very best solutions are OR team procedural standardization, and a recognition that humans cannot multitask.
“The whole idea that humans are able to multitask is a myth,” Harder says.
Harder began studying how surgical teams function at UM Medical Center and the Christiana Care Health System in Wilmington, DE, in 2004 and 2005. At the time, she says, “both had problems with retained surgical items: nine in 18 months at UMMC and six in two years at Christiana.”