Posted by John Ager on 15 March 2013.
“Never events” are defined as serious medical events which are so easily preventable that they should never happen. Inadvertently leaving a surgical implement inside of a patient is a never event. Surprisingly, it happens a lot – 4,500 to 6,000 times or more a year. When we think about retained surgical instruments, we often imagine the startling x-ray images of forceps or some other large metal object that was left inside of someone. While the shock value of such images in news stories is impressive, most of the time, a surgical sponge is the item that is forgotten. Because some surgeries require dozens or more sponges, and because they often can be hidden by the body’s anatomy and fluids during surgery, care must be taken to ensure that they all are removed before a patient is closed. This involves counting the sponges used before and after the surgery to be sure the numbers match. When they are forgotten, the consequences can be devastating, life-threatening and expensive.
Believe it or not, sponges equipped with inexpensive tiny transmitters are now available. They allow nurses to electronically track then going into and coming out of a patient. Perhaps more importantly, they also allow surgeons to pinpoint the location of any sponges which are not accounted for at the conclusion of a surgery. The technology has the potential to virtually eliminate human error in sponge counts, thus eliminating any compliations caused by a retained sponge, and costs about $8-$12 per operation. Yet, only about 15% of hospitals use them.
That statistic is surprising since the cost of a retained sponge hospitalization averages more than $60,000. Additionally, the related and usually justified malpractice suit (they call them never events for a reason) averages between $100,000 and $200,000. There are 32 million invasive surgical procedures in the U.S. each year. Even if every one were an open procedure with the potential for a retained sponge event using the technology, and a large number are not, the savings to be realized are staggering however you run the numbers – in the hundreds of millions of dollars.
Medicare does not cover retained sponge events and even small hospitals are often self-insured for at least $1 million. This means that looking at the total cost of a retained sponge event, rather than just the hard cost of sponge transmitter technology, makes financial sense when considering the sum value of the technology to the hospital, not to mention the value to the patient. Why then are only a small portion of hospitals using it? Beats me.
