The routine use of radio opaque markers may help in making sure correct sponge count in areas where it is available [1,2,5,6]. Abdomen was distended and tender, Pfannenstiel surgical incision scar noted. Hardwired systems are in place in the operating room to prevent the adverse event of a retained surgical sponge.
Conclusions Vigilance among operating theatre personnel is paramount if RSI is to be prevented.
Three days before presentation the abdominal pain got worse and involved the whole abdomen, vomiting become persistent, she failed to pass feces and flatus, developed fever and abdominal distension. When there is evidence of acute abdomen the decision to do laparatomy is easy but all attempts should be made to diagnose the conditions as early as possible by clinical evaluation and exhaust all available investigations.
Granted, when humans are involved, error is inevitable. Abdominal CT is an excellent study for this purpose which is missing in our patient 5—7. In the lumen of the small bowel FBs can cause either chronic small bowel obstruction or acute on chronic obstruction.
Misdiagnosis resulting delay of treatment contributes for the prolonged morbidity and even mortality, which is the case in our patient. Inaccurate counts are a main reason why tools can be left behind. Archived from the original on October 27, To make this judgement even more complex, the wife filed her lawsuit on August 9,two days under the three year anniversary of his death Estate of Genrich v.
Older publications were included if relevant. Migration of a retained surgical sponge into the bowel is rare compared to abscess formation .
The court determined that the negligent act occurred during the initial surgery.
Department of Health and Human Servicesit is anywhere between 1 in to 1 in He was taken to the operating room in order to remove the retained sponge.
Until she presented with signs of peritonitis she was treated for several conditions at different clinics and hospitals. For this, she was seen at different hospitals for several times and got unspecified treatments. FB in the large intestine can be passed per rectum.
The flaw with this technique is that gossypibomas are easily confused with abscesses. Gossypiboma can be avoided or incidences significantly reduced if surgical checklists are used seriously and routinely in every patient.
An increased amount of chaos and distractions lead to a higher risk of a surgeon forgetting a tool. One fact missing during the research of this case is the reason the wife waited three years to file a lawsuit.
The initial surgery occurred on July 24, The results obtained from these two studies are discordant mainly because of the low incidence of retained foreign objects along with the methodology used. Over the course of my seventeen year career as an operating room circulator, the fear of being involved in a case resulting in a retained surgical item was always on my mind.
This could be due to the fluid nature of the distal ileum content which can diffuse across the sponge and the acute presentation likely due to the perforation. Clinical presentation is varied, leading to avoidable morbidity, and the error is indefensible medicolegally.
Risk factors mentioned in literatures includes emergency operations, requirement of applying unexpected surgical procedure, obese patient, excessive blood loss etc [2,6,7].Providers using this technology have never experienced a retained sponge incident since deploying it.
Beyond the safety benefits, the economics to the hospital are usually compelling as well given the high cost of repeat surgery, legal fees, judgments or. The sponge that was left in the RETAINED SURGICAL SPONGE 4 abdomen caused the infection which ultimately resulted in the patient’s death (Estate of Genrich v.
Ohio Ins. Co., ). Conclusion In my opinion, the legal system failed in this case. Mar 08, · Watch video · That's up to twice government estimates, which run closer to 3, cases, and sponges account for more than two-thirds of all incidents.
Solutions ignored: The nation's hospitals have balked at using electronic technologies that sharply cut the risk of sponges being left in patients. The Problem of Retained Surgical Sponges and the Medical Malpractice Statute of Limitations By Regina A.
Bailey, J.D., M.D., LL.M. Candidate (Health Law) retained surgical sponge: gossypiboma.5 Complications from retained surgical sponge. A retained surgical instrument is any item inadvertently left behind in a patient’s body in the course of surgery. There are few books about it and it is thought to be under reported.
As a preventable medical error, it occurs more frequently than "wrong site" surgery. The consequences of retained surgical tools include injury, repeated surgery, excess. Retained surgical sponge events continue to occur despite the implementation of preventive surgical count policies, procedures, and adjunct technologies to manual counting.
Such intraoperative mistakes can cause chronic nonspecific symptoms during the early postoperative period.Download