On November 7th, the Canada Institute for Health Information (CIHI) released a report on how Canada’s health care performance compares to other OECD nations. The good news is that, in most of the 57 indicators, Canada’s performance is average (in 32 out of 57) or above average (for 13 out of 57). However, there are several areas of concern where patient care in Canada lags behind other nations, notably in the following areas:
- The frequency with which foreign objects, such as surgical tools, are left inside patients during surgery.
- The frequency of avoidable complications, such as lung clots, after surgery.
- The rate of obstetrical trauma or tears during (vaginal) childbirth. Canada’s rates are double the average for OECD nations and aren’t improving.
Tracy Johnson, the Director of Health System Analysis and Emerging Issues for CIHI commented that these issues are serious and often preventable and we need to improve our performance in order to achieve safer patient care in this country.
Some areas of patient safety are actually worsening: the rate of foreign objects left in patients during surgery has actually increased by 14 percent during the past 5 years. 553 objects were reported to have been left behind in Canadian patients undergoing surgery between 2016 and 2018. And, the national average for retained surgical items is 9.8 for every 100,000 surgeries. Sponges are the most common object left in a patient, but other surgical tools such as clips, forceps and needles are also sometimes left behind.
Unfortunately, we can’t compare Canada to peer countries because the U.S., Australia and the Great Britain are unable to report on the problem of objects being left behind. And, it's very likely these medical errors are occurring in our peer countries, we just don’t know how often.
In August 2012, a U.S. NCBI/National Library of Medicine study described a surgery in which a sponge was left behind during a subtotal hysterectomy. The sponge count was incorrect after the surgery was completed, but no sponges were found when the patient’s abdomen and pelvis were explored and a radiograph also didn’t indicate a retained sponge. So, the patient’s abdomen was closed. However, the circulating nurse continued to be concerned and convinced the gynecologist to request a CT scan, which revealed the lost sponge. A surgeon subsequently performed an exploratory laparotomy to find the sponge and remove it, and the patient made a full recovery.
Complications when foreign object is left behind
According to the NCBI study, a patient’s risk of complications increases when a medical tool or sponge is left behind during surgery. The retained foreign object may cause local or systemic inflammation, and can lead to infection, fistulas, adhesions, obstruction and/or sepsis. The most common symptoms after a foreign object is left behind are pain, tenderness and infection. And, about 2 percent of patients die.
Preventing medical errors that lead to retained surgical items
In 2008, the World Health Organization (WHO) introduced the Surgical Safety Checklist (SSCL) which led to a greater focus on checklists to improve safety in Canadian hospital operating rooms. The Operating Room Nurses Association of Canada also provide guidelines to nurses on how to perform surgical counts as well as procedures to reduce incorrect counts. During the period from January to June 2019, Ontario hospitals reported, on average, that the SSCL was completed 98.9 percent of the time.
However, clearly the procedures for completing the surgical count or resolving possible errors are not always being followed and/or not flawless, or the problem of retaining objects would not be occurring.
The NCBI study identified the surgical and communication problems and risk factors that can result in objects being left behind in a patient. The problem that most frequently contributes to retained foreign objects is poor communication within the surgical team: such as, when team members are in disagreement about incorrect surgical counts; they exclude key individuals from communications; or fail to properly communicate important information during perioperative personnel changes. And, if a retained object is suspected, team hierarchy and a lack of cooperation can inhibit the identification and correction of the error. Other risk factors include emergency surgeries and unexpected changes in operation.
In “Safe surgery: Closing the gap with the surgical safety checklist”, The Canadian Medical Protective Association (CMPA) examined Canadian occurrences of unintentionally retained surgical items (which included an 18 cm forceps) and identified the following reasons for the errors:
- The surgical counts were not recorded
- The counts were mistakenly reported as correct
- Imaging wasn’t performed despite the reported discrepancy in counts
- Additional or regularly used surgical items or parts were not added to the count
Also, the CMPA article noted that it frequently took weeks or months of investigation of post-operative symptoms before medical personnel identified the retained surgical items.
A person who has suffered injury, pain and/or financial losses due to a medical error, such as a retained surgical item, is entitled to seek damages against the hospital and/or medical staff who caused their injury. If you were injured and would like to learn more, talk to an experienced medical malpractice lawyer at Stevenson Whelton LLP and find out about your legal rights in the matter.