To err is human

November 17, 2008 § 6 Comments

unn_retained_sponge

The kind of flexible sponge left inside this patient. Photo: Ole Åsheim, Nordlys.

This week one of the worst cases of retained surgical instruments in Norway was unraveled. A patient saw his five operations for colon cancer in a year turn to six, when it was discovered the surgeon had left behind a 20 cm long flexible sponge. The unique aspect of it however, was the patient’s reaction.

The patient had had a colostoma for a year and was looking forward to getting his colon tucked back in and reconnected. About a week after the operation he had a fever, and on returning to the hospital an x-ray revealed the retained sponge. But that’s not the whole story. Not only had the sponge count gone wrong, but it was discovered that a radiologist had noted the foreign body on a postop x-ray report, but no one had acted on it.

In other words, the patient had all the reasons in the world to go ballistic and see his surgeon in court. But he didn’t. In fact, he asked for the same surgeon to remove the sponge. His comment to the newspapers was (my translation):

Do I have confidence in the hospital after this? Yes, I do. To err is human. (…) The surgeon did a terrific job of stitching together my colon, and I wanted him to finish it.

Terje Mortensen, VG

X-ray showing the sponge in the patient's abdomen. Photo: Terje Mortensen, VG.

I don’t know how I would react in his place, but I certainly admire his attitude. The hospital routines should have prevented this ever happening, and it would be fair to give the patient some sort of compensation for his troubles. But surgeons are not omnipotent deities, although they do have our lives in their hands. We should demand that they do their very best, but we cannot demand that they never do any mistakes.

It’s not that I don’t understand patients who do get angry when these things happen, but what makes the better surgeon: being allowed to learn from your mistakes and correct them, or to work under the constant threat of having your ass sued? Just asking.

Sources: Nordlys, Verdens Gang.

PS. If anyone knows the technical name for this sponge, please tell me. I know I’ve heard it, but I simply cannot remember.

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§ 6 Responses to To err is human

  • Jeffrey says:

    wow. what a rare occurrence. a normal patient would have demanded some sort of compensation for psychiatric distress caused by this ordeal.

    im not sure which one makes a better surgeon. it depends on how the surgeon reacts to things.

  • Now THAT is a sponge! I’ve never seen one like it so can’t help you with the name. What a noble patient. I assume that some lawyer will catch wind of the case and pressure the patient into filing a lawsuit so the lawyer can buy a new condo or that sports car he’s been dreaming of. At least that’s how it goes here in the U.S.

  • […] and the X-ray is striking, so here I link to the Sterile Eye, where Oystein shares the story of a remarkable patient who displays incredible forgiveness and wisdom, when his surgeon makes an awful and preventable mistake, leaving a sponge inside the […]

  • sponge man says:

    It is unfortunate that the hospitals was not using the Surgicount Safety Sponge system, which would have prevented the retained sponge incident from occurring. Surgicount Medical’s Safety Sponge system uses bar code technology to allow operating room nurses to accurately account for surgical sponges. Surgicount has been used in over 200,000 operations at hospitals including UC San Francisco, Loyola in Chicago, Shands Hospital at the University of Florida and many others. I believe that Surgicount will one day be the standard of care in operating rooms nationwide since it is the only way to ensure that all surical sponges are properly accounted for.

  • melissa says:

    gossypiboma is the name for a retained surgical sponge

  • nelc says:

    i guess to forgive is still human, ..

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