When Surgeons Leave Objects Behind

Another tracking system relies on bar code technology. Every sponge receives a bar code, which is scanned before use and scanned again as it is retrieved.
Electronic tracking can be a safety net when manual counting fails. Yet nationwide, fewer than 1 percent of hospitals employ it, said Dr. Berto Lopez, an obstetrician-gynecologist and the chief of the safety committee at West Palm Hospital in West Palm Beach, Fla.

Dr. Lopez became an advocate for electronic tracking after he was sued in 2009 for leaving a sponge inside a patient — an error that occurred, he said, after two nurses assured him that all sponges had been accounted for. He now refuses to operate in any hospital that does not use electronic tracking.
“When something bad happens to you, you get religion,” he said. “I’ve been rampaging ever since this happened. You study the subject, and you realize that this happens to a lot of people.”

Dr. Lopez, who said he had no financial interest in tracking systems, said that even though radio-frequency tracking is relatively cheap, many hospitals do not want the added expense.
“In my heart, I think it comes down to hospitals not wanting to spend the 10 bucks,” he said.
But Dr. Gibbs, of NoThing Left Behind, said technology should be only an adjunct to manual counting. Some hospitals now use inexpensive “counter bags” that resemble the shoe storage bags that hang from closet doors. Each sponge has its own compartment. If a compartment is empty at the end of an operation, a nurse can see that a sponge is missing. Then, Dr. Gibbs said, an electronic tracking system can help find the missing sponge.
At the same time, she added, sponge counts should not be the sole responsibility of nurses: Everyone in an operating room must share accountability. Surgeons can tell nurses where sponges are being placed, for example, and conduct thorough wound exams to look for sponges before stitching up a patient.
“Technology is but an aid,” Dr. Gibbs said. “The way that safety problems are corrected and fixed is by changing the culture of the O.R.”