Enhancing Surgery: A Hospital Shares Their Experience with the Melzi™ Sharps Finder

Mistakes are an inevitable part of life, and in the high-stakes environment of a hospital operating room, the repercussions can be staggering. That’s why hospitals implement stringent controls and procedures to minimize errors and ensure swift resolution if they occur.

But even with these controls in place, the most routine and meticulously performed surgeries can still sometimes veer off course, exacting a toll on the facility and, most significantly, the patients involved.

Let’s explore the prevalence of RSIs and how to prevent this never event in your facility.

What is a Sentinel Event?

A recent in-depth article in The Philadelphia Inquirer delved into several significant retained surgical item (RSI) events, shedding light on the profound impact of medical errors on patients’ lives. Let’s explore two examples from the article and the severe consequences of these never events.

Two Recent RSI Examples

In the first instance examined in the Inquirer article, a 29-year-old motocross enthusiast underwent what should have been a routine surgical biopsy. However, this seemingly straightforward procedure spiraled into a two-year ordeal. Unbeknownst to him, six to eight feet of surgical gauze were inadvertently left inside his chest during the biopsy. As the gauze became infected, it gradually expanded, constricting his windpipe and causing a constant struggle to breathe, bouts of coughing up blood, and debilitating panic attacks.

Despite persistent efforts to seek medical assistance and undergoing multiple procedures and tests, it took over two years for doctors to identify the root cause of his suffering. The toll on his physical and emotional well-being has been immeasurable, leaving him unable to pursue his passion and grappling with depression.

In the second example, a 76-year-old woman underwent a hip replacement procedure, but during the surgery, an orthopedic surgeon inadvertently left behind a trial femoral ball in her groin. Typically made of plastic, these trial balls serve as temporary implants to assess hip mobility before inserting a permanent device. What should have been a straightforward procedure for the patient turned into a distressing ordeal due to the oversight.

Serious Repercussions

In the case of the 29-year-old, the physical and emotional toll of the RSI was substantial, robbing him of his passion and contributing to a significantly different life from the one he lived before his routine surgery. And beyond the evident physical pain and emotional distress experienced by this patient, there are also financial burdens. The medical care required to address the repercussions of the oversight has already amassed an eye-watering total of approximately $250,000, including the direct costs (additional surgeries, treatments, and hospital stays) and the indirect expenses associated with prolonged recovery and rehabilitation.

Similarly, the older patient faced additional surgeries and prolonged medical treatment, further exacerbating the financial burden on her and the healthcare system. Such an unexpected financial burden can be overwhelming and debilitating for individuals already navigating the complexities of healthcare costs.

But it’s not just patients who bear the cost of these mistakes. RSI events pose significant financial burdens on hospitals and healthcare providers. The financial repercussions are substantial, with an average indemnity payment of approximately $473,000 for each incident and claims involving permanent patient damage averaging around $2,000,000. Moreover, individual physician indemnity can range from $105,000 to $865,000, adding further strain. Since these events are not reimbursable, hospitals are left to absorb the costs and settlements, underscoring the critical importance of implementing robust preventive measures to mitigate such risks.²

On top of that, RSIs tarnish hospitals’ reputations and erode the trust that forms the foundation of the patient-provider relationship.

The cumulative implications of these mistakes underscore the urgent need for enhanced preventative measures, rigorous adherence to safety protocols, and tools that OR teams can deploy fast to recover objects when these protocols fail or the unexpected occurs.

Preventing RSIs Must Be an Ongoing & Evolving Effort

It’s important to note that most medical professionals strive to provide the best care possible but are also human and susceptible to errors. While no one person may be at fault, there is still a collective responsibility to acknowledge the mistake, address its consequences, and work towards preventing similar incidents in the future. RSIs may be rare, but the consequences are far-reaching and must be prevented at all costs. Patient safety must remain a top priority for healthcare providers and institutions alike.

Acknowledging mistakes, implementing corrective actions, and fostering a culture of transparency are essential steps in mitigating the impact of never events such as RSIs. By embracing accountability and actively working towards preventive measures, the healthcare community can honor its commitment to patient safety and uphold the trust in its care.

In addition to fostering a culture of accountability, harnessing the latest technology and updating OR protocols can significantly contribute to error prevention. Advanced surgical tools like the Melzi™ Sharps Finder^™ can enhance inventory management and facilitate the accurate tracking of surgical items throughout procedures, potentially helping to prevent RSIs before they happen.

Get in touch today to learn more about Melzi and our patient safety mission.

Sources:

1. https://www.inquirer.com/health/inq2/medical-errors-surgery-philadelphia-hospitals-safety-regulations-20240403.html
2. Goodwin, B. JD, RN (2018, March 1). Retained surgical lawsuits will cost you. Retrieved from Urology Times: https://www.urologytimes.com/view/retained-surgical-item-lawsuits-will-cost-you