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The patient, 36, was having a cyst removed from her liver when the surgeon mistakenly left behind a pair of forceps.
Three years later, the patient excreted part of the forceps handle in her stool while using the bathroom.
After an X-ray revealed another piece of the metallic instrument still inside her, another round of surgery was scheduled.
The forceps had corroded and turned black, the grip was completely missing, and part of the woman’s digestive system had to be stitched together.
As a result of the preventable hospital error, the patient sued the doctor responsible for the incident, a mistake often characterized as “retained surgical instruments,” or RSIs.
The dangers associated with retained instruments vary. The outcome could “have catastrophic implications for patients, healthcare professionals and medical care providers,” authors of a 2013 study said.
The mistakes can lead to other issues, including hospital readmission, more surgery, infection, and bowel obstruction or perforation.
Various medical organizations have suggested a spate of potential fixes, including requiring a detailed count of instruments after surgery or using X-ray devices to ensure nothing was left behind, but the preventable mistakes continue.
While the number of accidentally retained surgical objects hasn’t typically been closely catalogued, medical estimates “of surgeries with objects left behind range from 1 in every 1,000 procedures to 1 in every 19,000” surgeries.
The Veterans Health Administration cites a rate of about 1 in 6,000 for its surgeries.
“Every year, an estimated 4,000 cases of ‘retained surgical items,’ as they are known in the medical world, are reported in the United States,” the New York Times published in 2012.
Sponges and towels were among the items most commonly left behind in patients, according to a study conducted by surgeons at Ohio State University’s Wexner Medical Center.
Researchers documented 59 cases of retained surgical instruments out of 411,526 surgeries. Medical sponges or towels were involved in 59 percent of the cases of RSI.
A technology called radio frequency identification is being studied as a possible solution.
A 2017 study determined that radio frequency identification (RFID) technology may “have the potential to substantially improve patient safety by reducing RSI errors, although the body of evidence is currently limited.”
“An RFID system consists of a tag, which is made up of a microchip with an antenna,” according to RFID Journal. Another device called a reader sends a signal using electromagnetic waves, which activates the microchip’s circuits. That changes the waves, sending information from the tag to the reader.
“Safety measures to eliminate RSIs have been widely adopted in the United States and abroad, but despite widespread efforts, medical errors with RSI have not been eliminated,” the 2017 study said.