The Surgeon

In December 2007, a jury awarded a plaintiff $10 million as a result of a doctor accidentally leaving a surgical sponge inside the plaintiff after his procedure. The increasing frequency of such verdicts, in combination with new government mandates regarding patient safety, are leading health-care providers to take a long-overdue look at new technologies designed to reduce so-called “never-events.” This is being accelerated by Medicare and private insurers’ newly announced refusal to reimburse the costs associated with preventable medical errors. Currently, hospitals attempt to prevent retained sponges by requiring nurses to individually hand count all the sponges that will be used in a procedure – tracking the sponge counts on a white board. At the end of the procedure, all sponges – both dirty and clean – are counted again by hand and reconciled with the original count. Leading patient safety researchers estimate that of the average 4,000 sponges a year accidentally left behind in patients, at least 88% percent of cases falsely recorded a correct sponge count. This manual method of counting sponges, which is prone to human error, was first established in the 1940’s with little change in the intervening sixty years.

Technology, however, has changed. Retailers, inventory and supply chain departments, and even the post office long ago implemented computer-based systems to reduce human errors in reconciling and counting items through scanners and bar coding. With this in mind, SurgiCount Medical, a division of Patient Safety Technologies, Inc. (OTCBB:PSTX), introduced its Safety-Sponge™ System in 2006. Based on the same low-cost, proven technology already employed by medical institutions for tracking patients, administering medications, and controlling inventory flow, the Safety-Sponge System prevents false correct counts by computerizing all sponge counts in an OR. As each individual sponge has a unique two-dimensional bar code, no one sponge can be counted twice and inadvertently create a false correct count. This essentially eliminates the root cause of retained sponges. As with all modern inventory management systems, the electronic records can easily be imported into a hospital’s paperless patient record system. This information can also be data mined to spot trends and to calculate the measured outcomes that hospitals often have to provide state and national regulatory and accrediting bodies. “When you consider that research indicates one in every 1,500 abdominal operations potentially results in a retained sponge¹, the need for computerized counting is clearly overdue,” says Bill Adams, CEO of SurgiCount Medical. “The Safety-Sponge System is a patient safety initiative every medical facility should embrace, not only to protect their patients, but to protect themselves as well.” By way of comparison, the other entrant in the new market of retained sponge prevention focuses not on the counting of sponges but rather on the detection of sponges in patients. These radio frequency-based systems stitch miniaturized radio beacons into individual sponges with the idea that they will be locatable by sweeping a wand over the patient. RF systems don’t track individual sponges, however, so they can’t inventory how many sponges were used at the beginning, and, more importantly, at the end of a procedure. RF systems also cannot provide hospitals with documentation of what transpired during the procedure. The winner of the 2007 Cardinal Health Award for Supplier Innovation of Patient Safety Technology, SurgiCount is now a surgical team fixture at numerous hospitals nationwide, as well as in teaching facilities at UC San Francisco, Loyola University Medical Center, and the University of Florida. “In the past, retained sponges were treated as an institutional speeding ticket,” adds Bill Adams. “Today, the problem is being treated as more of an institutional DUI by the insurance and accreditation agencies. The good news, though, is that both perioperative nurses and medical facility administrators are now embracing this potentially life-saving technology as part of their commitment to making sure ‘never events’ never happen again.”

Editor’s Notes:

* It’s estimated that there are 3,000 to 5,000 cases of retained sponges annually¹.
* Sponges left behind can cause deadly infections (with patients and doctors unaware that the infections are RFO-related) and can lead to mortality.
* Several states have initiated mandatory reporting policies calling for hospitals to annually disclose preventable medical errors (often called “never events,” as in “never-should-happen”).
* Medicare, Blue Cross and Blue Shield all announced plans last year to stop paying hospitals for the treatment of conditions which fall into the “never events” category (such as re-doing a surgery for $50,000 after a sponge has accidentally been left inside a patient).
* Since the introduction of codified AORN (Association of Perioperative Registered Nurses) sponge-counting recommendations in 1976, little has been introduced by way of adjunct technology to assist nursing staffs in performing their manual counting procedures and in reducing instances of lost or retained sponges.
* The Joint Commission, which accredits hospitals, is strongly suggesting that healthcare facilities implement systems to prevent RFO-based errors.
* The average cost to hospitals per retained incident is $250,000.