Joint Commission calls for better counting to prevent surgical errors

Joint Commission wants better counting to prevent surgical errors

When an object is left behind during surgery, such as a sponge, a needle, or some other small fragment of a tool — a patient can end up in severe pain. In a small number of cases, these types of surgical errors — leaving instruments behind — even lead to death. Considering the fact that these types of surgical errors are 100 percent preventable, more needs to be done to better protect patients.

The Joint Commission, which is a nonprofit health care safety watchdog organization, recently released a report showing the prevalence of these types of surgical errors, proving these types of mistakes happen more than most people probably realize.

According to the report, there were close to 800 incidents where objects were left behind inside of a patient between 2005 and 2012. Of these incidents, 16 people died. In 95 percent of the cases where an object was left behind, the patient ended up having to stay longer than originally expected in the hospital due to the error.

The report also found this type of error is most common when the operation is an emergency. In fact, leaving behind an object was nine times more likely during an emergency surgery. An object was also four times more likely to be left behind when there was an unexpected change during the procedure.

Overall though, the Joint Commission found more needs to be done to foster better communication between staff and to better educate the staff. With this report, the commission also calls for better counting protocols in order to ensure no objects are left behind.

The commission recommends a counting system where two staff members — a nurse and a tech — count equipment and write the number on a white board before surgery. The equipment is also counted before the cavity is closed and after the procedure. Each time these objects are counted, the number if verified by a surgeon and written on the board. This way, every member of the surgery team is involved, even if it is just seeing the numbers on the board.

So far, one children’s hospital has tried such a counting system and reported a 50 percent reduction in errors.

Looking to the future, the hope is more hospitals will adapt similar procedures in order to provide the best care possible for patients.

Source: CBS News, “Nearly 800 surgical tools left in patients since 2005: Report,” Ryan Jaslow, Oct. 18, 2013

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