Mystery Materials: Is It Malpractice?

This month’s newsletter reviews a claim in which the patient alleges the physicians and nursing staff failed to properly perform a surgical count resulting in retained foreign materials within the patient’s body.

The claim involves two physicians participating in a patient’s surgery–an anterior/posterior decompression and fusion at L5-S1. The patient tolerated the procedure well without complications. Both physicians verified that the surgical counts for the needles, sharp instruments and sponges matched at the beginning and end of the case. The physicians concurred that the counts were correct at the time of surgery and that numerous x-rays taken after the surgery did not show any foreign material present. The nursing staff’s documentation in the medical records also supports the accuracy of the surgical counts.

Almost 5 months later, one x-ray indicated that a partial needle was found in the area of the abdominal scar tissue caused by the surgery. Further complicating the issue, both physicians testified that they did not use the needles in question during this procedure. In fact, they never use the particular type of needle found in the patient. In addition, the physicians also testified that the nursing staff would not have utilized any of these needles during the procedure in question because the nurses play no role in the actual suturing of the patient.

The Medical Review Panel found the physicians did not breach the applicable standard of care as the surgery was performed without complications and the surgical count was confirmed by both physicians and nursing staff. They also found the nursing staff did not breach the applicable standard of care because they followed proper procedures by documenting and verifying the surgical count.

While we can only speculate as to how the odd needle made its way into the patient’s scar tissue, this case speaks to the importance of following policy and procedure by documenting the proper performance of a surgical count. It also illustrates that no matter how diligent we are, the unexplainable still may happen.

This case is a prime example of the importance of proper documentation and staff education. In this case, the staff’s knowledge and competence with hospital processes and thorough documentation helped defend the organization.

Surgery staff play a vital role in the operating room by ensuring that surgical counts are performed collaboratively by the entire surgical team and distractions are minimized so that the process is conducted in a safe effective manner. It is imperative that organizations ensure all staff is trained in hospital policies, procedures, and documentation related to surgical counts during orientation and through annual competency. Sharps and miscellaneous items should be counted on all surgical procedures at various times throughout the procedure. Needles, such as the one found in this claim, account for approximately 50% of foreign objects left behind during surgical cases. Organizational policies on surgical counts should be coordinated around best practices for surgical counts in order to prevent foreign objects from being left inside the body. Organizations should:

1. Incorporate best practices for surgical counts into their policies.
2. Educate nursing staff on surgical counts and proper documentation.
3. Educate medical staff on proper operating room procedures, including surgical counts.
4. Ensure that the entire surgical team is included in the surgical count and distractions are kept to a minimum while the count is being performed.
   

Additional Resources:

• Implementing AORN Recommended Practices for Prevention of Retained Surgical Items

• Association of Surgical Technologists Recommended Standard of Practice for Counts