Goof that left tool inside patient wasn’t UW hospital’s first

Associated Press

SEATTLE — When surgeons at the University of Washington Medical Center left a 13-inch tool in a patient last year, it wasn’t the first time the hospital’s doctors had sewn somebody up without taking everything out.

Nor was it the last.

In five cases since 1997, metal surgical instruments have been mistakenly left inside patients. The most recent was in September, when for a second time doctors forgot to remove a malleable retractor.

All of the instruments were removed in subsequent surgeries, and none caused lasting damage, hospital officials said at a Friday news conference held to explain past errors and underscore the commitment to prevent future ones.

"Our reputation is important in the community," said Kathleen Sellick, the hospital’s executive director.

The first of the retractor cases occurred in June 2000, when doctors removed a 13-pound cancerous tumor from the stomach of Don Church, a Lynnwood pest-control technician. The malleable retractor was removed two months later and, two weeks ago, the university agreed to pay Church $97,000 for the mistake.

The second case occurred in September during a complex abdominal surgery, the hospital said. That device was removed from the patient in October.

"We have accepted responsibility for this error and apologized to the patient," said medical director Dr. Eric Larson.

A malleable retractor looks like a metal tongue-depressor and is used to press down intestines and other internal parts while a patient is stitched up.

Other instruments left behind included a cardiothoracic retractor in February 2000, a cardiac retractor in November 1997 and a clamp in March 1997. The retractors used in heart surgery range from 6 to 10 inches long. The type of clamp left behind ranges from 6 to 12 inches long.

"The Church case, it surprised us," Larson said. "When it happened again was when we realized this is a real risk."

Following the mistakes, the hospital has introduced a new policy, requiring surgical teams to count all instruments used in surgery to make sure all are accounted for. Previously, only small instruments, such as needles, were counted.

Larson said the five cases represent one such mistake per the 12,000 surgeries the hospital performs every year — less than 0.01 percent.

"I think that’s low. I hope it’s low," he said.

Statistics on such mistakes nationwide are lacking, Larson noted.

The hospital’s staff is working "to discover ways to improve our processes and aims for zero defects," he said.

In addition to counting, doctors may request post-operative X-rays to ensure no instruments are left. In two of the five cases, X-rays caught the mistakes before the patients left the hospital.