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Objects such as sponges were left inside surgical patients in Utah 25 times last year.
That's the finding of an annual report released Wednesday by the Utah Department of Health.
The report does not detail exactly what objects were accidentally left inside patients at hospitals and surgical centers, however, the health department acknowledges sponges are frequently involved. There may have been some cases involving metal guide wires.
Those were among a total of 101 "sentinel events" in 2009 - serious medical mistakes that can be fatal in extreme cases.
That number is up from 80 in 2008.
The increase may be due to better reporting. The number of event categories expanded in 2007, and more hospitals now are participating with the health department in issuing the report.
Whether it's a sponge, a towel or a surgical instrument, the idea of having surgeons sew up a patient with a foreign object left inside gives plenty of people pause before surgery.
There were 21 more errors or mishaps last year than in the previous two years, and 54 of them occurred either in surgery or in procedures that were not performed as specified.
Iona Thraen, patient safety director at the Utah Department of Health, said sponges — large pieces of gauze used to stop or absorb bleeding — are the most common items left inside patients because they can be hard to spot after surgery.
"It's the equivalent of giving you 371 $1 bills in a wad," she said of the sponges, "and soaking them all with blood, then having to count every one of those with the patient lying on the table."
A couple of the foreign objects left in patients were metal guide wires that surgeons use to move through tight spaces that break off inside patients, Thraen said. The health department is most concerned about the objects that are "left unknowingly" rather than those where retrieving the object would cause greater risk or harm to the patient than leaving it, she said.
Other events logged in the report include surgery on the wrong body part, medication errors, pressure ulcers and patient falls.
Deb Wynkoop, director of health policy for the Utah Hospitals and Health Systems Association, said some of the increase in the number of mishaps came as a result of adding three new hospitals and a few new surgical centers within the state in 2009, increasing the number of patients being treated.
The number of errors reported has grown exponentially in the past three years, particularly, she said, as the number of categories that are surveyed for errors increased from eight to 32 beginning in 2007.
She said it's important to put the numbers in context, noting there were more than 152,000 hospital-based outpatient surgeries in 2008 in Utah, and that number rose last year.
Utah's number of errors reported is roughly equivalent to that in Minnesota, Thraen said, taking into account the differences in population. "I'm actually quite pleased. We've been criticized in the past for not being aggressive enough," but Utah's rule-based approach to reporting errors is resulting in the same level of reporting errors as Minnesota's legally mandated reporting, she said.
"The best way to prevent these events, which can be devastating to patients and their families, is to have a robust, transparent reporting system to monitor and track them," Thraen said.
"If we can better track these events we can work together with the health care industry to identify what's causing them and take steps to prevent them in the future."
http://health.utah.gov/psi/pubs/sentinel_events09.pdf
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