No object left behind? We’re not there yet.

 What happens when an object is unexpectedly left inside a patient after surgery?  In some cases patients suffer no adverse effects, in others life-threatening complications can develop.  In a effort to avoid this problem and enhance patient safety, various items used during surgery are counted before and after a procedure.  While it seems that process should solve the problem, statistics prove that instruments, sponges, needles, and even towels are accidentally left behind more often than patients might imagine.

Hospital risk management is always concerned about the potential of retained foreign bodies after surgery. Both from a patient safety perspective and from a financial liability perspective. Even more so now that objects unintentionally left in a patient after a surgical procedure will cause a decrease in reimbursement.   

To those of us who don’t work in an OR setting, it might seem that the nurses charged with ensuring correct counts simply aren’t paying attention when things get left behind.  Like most complications in healthcare, it’s not such a simple equation. 

Surgeries can be long; nurses and other personnel may come in and out of the room.  Interruptions while counting are the norm rather than the exception.  Many surgical items come in packages.  If the package says 10, a count of 10 goes on the record.  What if an 11th item was accidentally included during packaging, or only 9?  Needles can easily be dropped.  Did it fall on the floor, into the trash, or into the patient?  The search ensues in a room crowded with people, equipment, and bloody objects.  If the object can’t be located X-rays may need to be taken and read.  Sometimes retained foreign bodies show up plainly, sometimes not. 

In the meantime, precious minutes tick by for both the patient and the OR team.  Add to that the fact that operating room time is expensive and often in short supply.  The pressure can be intense to finish and move out of the room so that it can be cleaned for the next patient.

The root of the problem however, is often communication.  Surgeons and nurses are supposed to communicate freely during a procedure, after all they’re a team, right?  What often happens instead is eloquently described in a column in Maggie Mahar’s blog Health Beat.  A husband describes his OR observations during his wife’s C-section.  It is a disturbing and disheartening account.  Disheartening because the issues described are deeply ingrained into the culture of many healthcare organizations.

As with most cultural shifts, change will come about slowly, one doctor, one nurse, one administrator at a time.


Hospital Compare Website Adds Pneumonia Death Rate to the Mix

Healthcare consumers now have another key data element to review when comparing hospitals.

The Health and Human Services Hospital Compare web site now displays death rates from pneumonia, as well as death rates from heart attack and heart failure for individual hospitals across the country.

These numbers can be compared with the national mortality rate for heart attack (16.1 percent), heart failure (11.1 percent) and pneumonia (11.4 percent).

CNN reports on this development in Hospital Death Rates for Key Conditions Unveiled.

Baby Love

 This weekend I looked for the fist time into the eyes of my new niece.  What promise a baby brings to a family.

Will she grow up to be kind and warm-hearted?  She comes from kind, warm-hearted parents, so I have high hopes for her.  Will her spirit be light-hearted and sunny, or thoughtful and pensive? 

Will she take after Mama and tenderly care for those in need, or will she be like Papa and speak the secret language of computers? 

What fun it will be to get to know this little one.

But don’t hurry to grow sweet baby, let us hold you close for a little while.

See No Evil

“It’s a problem that goes underreported, threatens patient safety and has become so ingrained in health care that it’s rarely talked about,” so says Mark Chassin, President of the Joint Commission.

What is this dark, seldom-mentioned secret plaguing modern medicine?   

The aggressive, unpleasant, and even abusive behavior of bullies.  Their numbers are small, but their impact isn’t.  Sometimes they’re doctors, sometimes nurses, sometimes administrators, but their outrageous behavior is absolutely detrimental to the delivery of safe patient care.   

JoNel Aleccia of MSNBC discusses the matter in Hospital bullies take a toll on patient safety.

The Joint Commission recently released a Sentinel Event alert pertaining to Behaviors that Undermine a Culture of Safety.

Nick Jacobs, CEO of Windber Medical Center in Pennsylvania, reports that he and his family were hassled the last time he tried to address this issue.

The culture of many healthcare organizations allows, and even encourages, this unacceptable pattern of behavior, especially from high-dollar revenue generators. 

It’s past time to take this matter seriously.

Transparency and Disclosure – Very Scary

For most healthcare organizations the concept of transparency is big and scary.  It isn’t what we’ve done.  Legal privilege, confidentiality, peer-review; that’s what we’re used to invoking when care goes wrong.

And with good reason.  

Healthcare leaders don’t want events and near-events swept under a rug of secrecy. Process problems can’t be fixed if no one with authority to fix them knows they exist.  Yet, if a provider makes an error and suspects that reporting it will likely lead to public disclosure, the urge to cover over the transgression can be considerable. 

Upon investigation, seldom does an adverse event turn out to be a simple matter of one person’s failure.  When organizations choose to respond to an event by “rolling” a few heads, often there’s no guarantee that the same event won’t happen again the next day.  Root cause analysis may reveal that policies aren’t clear, or they aren’t enforced; equipment is not well maintained, or staff members aren’t effectively trained on how to use it; documentation isn’t complete, or it’s completely illegible. 

Line up enough of those circumstances and eventually a catastrophic error occurs.  Pity both the poor patient and provider at the end of that line. explores this issue further in the article:  Hospitals shine light on mistakes by publicly saying: “We’re sorry”

CMS Adds Three HAC’s to its “No Pay” List

CMS has added three additional hospital acquired conditions (HAC’s) to it’s list of events that qualify for reduced reimbursement as of October 1, 2008.

In last year’s final rule, CMS listed eight preventable conditions for which it would not make additional payments.  In this year’s proposed rule, CMS identified nine potential categories of conditions, but based on public comments, is finalizing three of these.  The new additional conditions in this year’s final rule include:

Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity

Certain manifestations of poor control of blood sugar levels

Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

The final rule will appear in the August 19, 2008 Federal Register.

Read CMS Press Release

Read July 31, 2008 CMS Payment Guidance Letter

Previous blog posts on CMS payment reductions: