Why do surgeons leave objects inside patients? | Shapiro, Washburn & Sharp

Surgeons leaving objects inside patients after surgery, also known as “retained surgical items” or “foreign bodies,” is a serious medical error that can have devastating consequences for patients. While the occurrence of such incidents is low, it remains a concerning issue in the healthcare industry. Understanding the reasons why surgeons may inadvertently leave objects inside patients is essential for preventing these incidents in the future. Several factors contribute to this medical error.

Surgical Complexity and Distractions

Surgical procedures can be highly complex, involving numerous instruments, sponges, and other equipment. During a complex operation, surgeons and their team members may become distracted or overwhelmed, leading to instrument oversight or miscounting. High-stress situations, emergency surgeries, or unexpected complications during a procedure can exacerbate distractions and increase the likelihood of errors.

Inadequate Communication and Teamwork

Effective communication and teamwork among surgical team members are crucial for preventing retained surgical items. Communication breakdowns, misunderstandings, or a lack of clear protocols for counting and tracking surgical instruments can contribute to errors. In some cases, changes in the surgical plan or unexpected events may not be communicated, affecting the count of instruments used during the procedure.

Inaccurate Counting Procedures

Surgical teams typically employ manual counting procedures to keep track of instruments and sponges used during a procedure. However, manual counting methods are prone to human error. Miscounts or discrepancies in the count can occur due to distractions, interruptions, fatigue, or inadequate training in counting techniques. Additionally, the use of outdated or ineffective counting protocols may contribute to inaccuracies in the surgical count.

Instruments Blending into Anatomy

Some surgical instruments, such as small sponges or needles, may inadvertently blend into the surrounding anatomy during the course of a procedure. In complex surgical fields or areas with abundant tissue, it can be challenging for surgeons to visually identify every instrument used. This can increase the risk of leaving items behind unintentionally, especially if they are not detected during the final sponge and instrument count.

Lack of Standardized Procedures and Technology

Variations in surgical protocols and practices across healthcare facilities can contribute to inconsistencies in preventing retained surgical items. Standardized procedures for counting and tracking surgical instruments may not be universally implemented or enforced. The lack of technological solutions, such as barcode scanning systems or radiofrequency identification (RFID) technology, to aid in instrument tracking and inventory management can also hinder efforts to prevent errors.

Fatigue and Burnout

Surgeons and surgical team members may experience fatigue or burnout due to long hours, demanding workloads, and the emotional toll of caring for patients. Fatigue can impair cognitive function and decision-making abilities, increasing the risk of errors during surgery. Addressing issues related to fatigue and promoting physician well-being is essential for mitigating the risk of medical errors, including retained surgical items.

Time Pressure and Efficiency Demands

In some cases, there may be pressure to complete surgical procedures quickly and efficiently, leading to shortcuts or oversight in the counting and retrieval of surgical instruments. Surgeons and their teams may feel rushed to finish a procedure, especially in busy operating rooms or when facing scheduling constraints. This can compromise thoroughness and attention to detail, increasing the risk of retained surgical items.

Human Error and Fallibility

Despite rigorous training and experience, surgeons and healthcare professionals are not immune to human error. Mistakes can occur due to lapses in attention, memory, or judgment, particularly in high-pressure environments such as the operating room. While efforts are made to minimize errors through training, protocols, and quality improvement initiatives, human fallibility remains a challenge in healthcare delivery.