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Mistakes In the OR: Leaving Instruments in Patients

November 19, 2010

(Ivanhoe Newswire) — For pediatric surgeons, the mistake of leaving an instrument in a child’s body is a dangerous and costly one.  A recent study performed at the John Hopkins Children’s Center found that the rare occurrence is usually not fatal, but is still a harmful, expensive and avoidable error.

Complications resulting from the mistake, and its requirement of a follow-up surgery, add an average of eight days to a patient’s hospital stay and an extra $36,000 in hospital fees.

The researchers of the retrospective study, who looked at 1.9 patient records spanning a period of 17 years, found 413 reports of the mistake.  At greatest risk of the error were teenagers undergoing gynecological procedures, who were four times more likely than other patients to experience it.

Trailing this group were patients requiring gastrointestinal surgery, who constituted 22 percent of the 413 cases.  Other significant groups were the patients of cardio-thoracic surgeries and orthopedic surgeries, constituting 16 percent and 13 percent of the cases respectively.

The 1.7 percent death rate of these patients was found to be slightly higher than the 0.7 percent death rate of control patients, but the discrepancy was too small to be a substantial indicator that forgotten surgical instruments increased the likelihood of death.

Information for the study was collected after the fact, so possible contributing factors such as operating room conditions and typical surgical routines were not considered.

“It’s important to find out what mistakes me make as surgeons, but it is infinitely more important to know why we’re making them and how we can prevent them,” lead investigator and pediatric surgeon Fizan Abdullah, M.D., Ph.D. was quoted as saying.

SOURCE: Johns Hopkins Medical Institutions, November 2010




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