Surgical Error Proofing

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WSJ.com – ‘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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