A few days ago, the Joint Commission issued a sentinel event alert on "Unintended Retention of Foreign Objects," also known by the acronym "URFO." This is when sponges, surgical tools or other objects are left in the body cavity after surgery. The Joint Commission is the accrediting agency that qualifies most American hospitals for Medicare, so these rare alerts lead the health care news.
Although I have great respect for the Joint Commission, the name they chose for this error is almost as nauseating as the error itself. Surgical patients are not shoplifters "retaining" a retractor or a sponge; they are victims of a catastrophic error made by providers in the operating room (OR). And the acronym "URFO" sounds like something from the old 1970s sitcom Mork and Mindy. For these reasons, I'll refer to this error here as "foreign objects left in."
This awful mistake is the #1 most common sentinel event reported to the Joint Commission, but the true incidence rate is not precisely known. The most cited study was a four-year project at Mayo Clinic and five large teaching institutions covering 411,526 surgeries, which found an incidence of one in 5,500 operations. But that doesn't mean patients have the same chance of suffering this disaster at every hospital. My nonprofit organization, The Leapfrog Group, reports on objects left in at most general hospitals in the country, as part of the data we use in assigning a letter grade on how safe the hospitals are. We find that some hospitals are ten times more likely to leave objects in than the average hospital. A good number of hospitals never leave objects in, which should be the norm.
Sponges are by far the most common item left in the body. If you haven't witnessed an operation before, surgical sponges are different from your kitchen scrubber. Usually they are thin squares that look like cotton bandages. Dozens or even hundreds can be used in a single procedure, and it is very easy to overlook one in the body cavity, especially when they are soaked with blood.
But they can cause a great deal of suffering. As reported in USA Today last spring, an undetected sponge left in Erica Parks after her Cesarean section caused her excruciating pain for several weeks, ultimately shutting down her bowels. It took a six hour surgery to remove the infected mass from her intestine.
Erica was lucky enough to survive. A sponge left in Geraldine Nicholson's body caused a series of heartrending and debilitating complications, which in turn disqualified her from receiving cancer treatment that could have saved her life. She died after a one-year stay in the hospital.
Hospital ORs have procedures in place to count and account for all the instruments and sponges used in the procedure. But the Joint Commission alert warns that "current practices for counting sponges have a 10 to 15 percent error rate."
The $10 Fix Every Other Industry Already Knows About
There is technology available for hospitals to get a more accurate count. It's not particularly complicated; sponges can be barcoded and/or tagged with radio frequency systems that go "beep" when you wave a wand over the patient. Studies suggest these systems work and significantly reduce that high hand-counting error rate. They add about $2 to $10 to the cost of a surgery. Yet, astonishingly, according to the USA Today report only about 15 percent of hospitals use any of this technology.
Pretend for a moment that your corner grocery store still had cashiers punching prices into a keypad on the cash registers. Now imagine that the owner of this old-fashioned establishment asked you for advice. "I've noticed that ten to fifteen percent of the time, my cashiers accidentally key in the wrong price," says the old-fashioned grocer, "What should I do to reduce that error rate?" What would you suggest to him?
A. Assign additional employees to check the sales receipt after every purchase and check each customer's grocery cart before they leave the store.
B. Purchase the barcode scanners that every other grocery store in America successfully uses.
If you picked B, congratulations, you are truly a denizen of the 21st century. If you picked A, you are currently residing in the 1970s, and your grocer will spend a lot of money, annoy his customers and still have lots of errors on the cash register receipts.
In the operating room theater, where the stakes are higher than a few misplaced digits on a grocery receipt, the Joint Commission seems to have picked A, the recommendation from Mork and Mindy's era. The alert advises hospitals that to avoid URFOs, people in the OR need to check and recheck, count and recount. When the surgical count doesn't square, the Joint Commission recommends an X-ray. The Joint Commission does advise hospitals to "research" the idea of using new technology. I don't think any industry other than health care thinks they need to study whether barcoding is a good idea or not, but I'll save hospitals some time: There's lots of published and peer reviewed research to prove that it works.
What We All Must Do
Objects are left in because consumers and businesses aren't holding hospitals accountable for the problem. When was the last time a hospital saw its health plan negotiations go south because they left a few objects in? What consumer ever refused to be admitted to a hospital because they didn't like its safety record?
Medicare isn't helping either. Recently the Centers for Medicare & Medicaid Services (CMS), the agency that funds Medicare, announced plans to stop publicly reporting on objects left in by hospitals serving Medicare beneficiaries. We've been working to reverse this.
In addition to advocating for the public data you deserve, purchasers and consumers will need to monitor Hospital Safety Scores and Leapfrog data, and use it to make decisions about choosing safe hospitals. When hospitals scrimp on safety, employers and patients pay -- in suffering and in real dollars. Employers can calculate just how much they are paying today for that suffering on Leapfrog's calculator of the hidden surcharge Americans pay for hospital errors.
What's clear is that hospitals don't understand that their customers expect them to put their safety first. It's long past time for all of us to change that.