WCCO-CBS, Minneapolis covers latest SurgiCount implementation
Original article and video available here
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Feb 27, 2009 11:12 pm US/Central
New Scan Counts For Surgical Sponges Left Behind
Reporting
Dennis Douda
ROCHESTER, Minn. (WCCO) ―
Nearly 100,000 people die each year in the United States because of medical mistakes. Now, Mayo Clinic is the first facility in Minnesota to bring safer surgeries into the operating room.
In the operating room these days it has become routine to check, double check and triple check.
There is even a "Pause for the Cause" as the entire surgical team stops to confirm what, where and upon whom a procedure is going to be performed. Still, medical errors happen.
"In about one in 5,000 operations there is some type of retained object," said Dr. Robert Cima with the Mayo Clinic Quality in Surgery Department.
Retained inside the patient, where they can cause life-threatening complications like infection, even decades later. Most commonly left behind are surgical sponges, those sterile cloths used to absorb blood and fluids.
"A minor procedure can be just maybe five or 10. But, for a big cardiac procedure, orthopedic procedure of the back, you can look up to upwards of 200, 250, 300 sponges," said Cima.
Now imagine keeping count of each and every sponge going in and coming out, while lab reports are coming in, blood is being delivered or the nursing team has a shift change.
Cima said when they investigated cases of a sponge being left behind in a Mayo procedure; they found that 70 percent of the time the count was recorded as right. Apparently they had hit the edge of what he calls the "human performance barrier."
"We just couldn't get any better without something new," he said.
The "something better" is technology. The first week of February, all 100 of Mayo Clinic's operating and procedure rooms started using sponges with bar codes. Each one has a data tag with a unique number woven into the fabric.
It is an FDA-approved computer tracking system by Surgi-Count Medical.
The system keeps track of who did the scanning and patient IDs. It records a master tag for each bundle as they are put into service and accounts for each used sponge before they are discarded, greatly reducing the chance of leaving any behind.
"It won't let me double count a sponge," said Surgical Nurse and safety team member Jack Clark.
Clark says it does not replace manual sponge counts, but adds a whole new level of accuracy.
"The machine never gets tired, never gets distracted and it's there to reinforce our counting techniques," he said.
Mayo's safety team says bar codes on sponges are just the beginning. Before long, many instruments may carry bar codes.
Allergies, medications, and test results may all be integrated into the same tracking system.
Cima said many people are not aware how easily the soggy sponges can shrink and become camouflaged in a surgical site, and Mayo helped Surgi-Count Medical refine their system for two years before adopting it in the OR.
