Surgical Error Proofing

0 – ‘Tagged' Sponge Beeps If Doctors Leave It Behind

Leaving foreign objects inside the body after surgery is a problem that plagues hospitals.

One earlier study found that medical personnel left foreign objects, most often sponges, inside a patient's body in one out of every 10,000 surgeries, causing complications that can include death.

It's something that should be error proofed using a lean “poka yoke” approach. One low-tech approach is keeping inventory of items and counting them after surgery.

A company and Stanford University are testing a high-tech approach with RFID tags. It's not the highest level of poka yoke — something that would prevent the problem from occurring would be best. The RFID approach is really a method that allows easy inspection at the source, a lower form of poka yoke. This finds the problem after it has occurred, but while still on the table. Still, it's better than leaving a sponge inside of someone.

Doctors at Stanford University School of Medicine who tested sponges embedded with radio-frequency identification tags said the system accurately alerted surgeons when they deliberately left a sponge inside a temporarily closed surgical site and waved a detector wand over it.

But they said the size of the chips used — about 0.8 of an inch — was too large and would need to be reduced to be practical on sponges and surgical instruments.

Alex Macario, a physician and professor of anesthesia who led the study, said the future probably will see a combination of tags and other techniques such as counting instruments and sponges before and after an operation.

“We need a system that is really fail-safe; where, regardless of how people use this technology, the patient doesn't leave the operating room with a retained foreign body,” he said.

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

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