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
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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