The People's Perspective on Medicine

Did Surgeons Really Leave 16 Items Inside Patient?

Most people do not look forward to surgery. Even great surgeons can sometimes make mistakes. Are there ways to reduce the risks. What questions should you ask BEFORE surgery?
Medical error medical mistake doctor error wrong site surgery

It is one of those stories that sends shivers up and down our spines. Next to operating on the wrong patient or the wrong body part, leaving surgical “stuff” inside a patient’s body tops our list of “never events.” These are things that are NEVER supposed to happen during surgery. In theory, surgeons and their assistants are supposed to check for sponges and other equipment before closing. Sometimes, though, there are serious mistakes!

What Got Left Behind?

The latest story of an incredible screw-up that should never have happened apparently involves a German patient named Dirk Schroeder. According to reports from Europe, Mr. Schroeder, 74, underwent what was supposed to have been “routine surgery” for prostate cancer.

After the surgery, however, he experienced significant discomfort. The pain was such that he had difficulty sitting down. In some accounts it was described as “appalling agony.”

In Germany, nurses often make home visits to follow up on senior citizens in distress. During just such a visit a nurse discovered a large gauze pad protruding from the surgical wound. Subsequently, he went back to the hospital for exploratory surgery to see what was going on.

16 Items Left Behind…Really!

During two separate operations surgeons allegedly removed 16 items including a needle, cotton swabs, a 6-inch bandage roll, a 6-inch compress, a piece of a surgical mask and goodness knows what else.

One has to wonder what happened during the original prostate surgery that could have led to such oversight. Were these surgeons and nurses partying at the patient’s expense? Who was counting swabs? Was anyone paying attention?

The Hospital’s Explanation Defies Imagination:

But wait…it get’s stranger. The hospital’s response was that all these surgical “left-overs” somehow entered the patient’s body AFTER the surgery was completed and the wound closed. Huh? How exactly did this stuff wander from the outside to the inside of Mr. Schroeder’s body after the surgery was complete?

Guess how much the hospital offered the family to settle the case? (Mr. Schroeder died last year.) According to the family lawyer, the hospital initially offered $660 to get the family to go away and stop complaining. We’re not surprised they didn’t agree to this settlement. The family was reportedly asking for $127,000 in damages.

Surgical Errors in the U.S.

In the U.S. few, if any, malpractice attorneys would take on such a case for a sum of that size. The expense to bring such a lawsuit to trial could cost nearly that much and wouldn’t be worth a lawyer’s time.

We thought this case was worthy of your attention because it reinforces a study published in the journal Surgery (online Dec. 17, 2012) titled “Surgical Never Events in the United States.” The investigators from Johns Hopkins estimated that 40 times every week in the U.S. sponges, swabs or other “stuff” is left behind in a patient after surgery. To read more about this debacle, click on this link.

Stories from Readers:

Here are some comments from visitors to our website about their surgical experiences:

C.M. had problems with the anesthesia:

“I had a back operation recently and as a result of the anesthesia, I had hallucinations afterward.
“It took me a month to get my brain back to normal. I would ask for a ‘cup of coffee’ and it would come out as ‘a cup of carrots.’

“I thought is was just me but I have talked to people since and they have told similar stories. What are they using in anesthesia now a days?”

J.S. also reports on post-surgical problems with family members:

“Both my grandfather and my father had hallucinations after surgery, whether due to anesthesia or pain meds, I don’t know. We had to have someone stay with them round the clock.

“My grandfather suffered a broken cheekbone trying to get out of bed, swearing he was being attacked. My dad ripped out his catheter and attacked a nurse. Neither one of them was violent when in their right minds.

“Fortunately, they both returned to normal after they were off the meds and back home. Even being prepared, as we were after the first incident, it was awful to watch a loved one go through that.

“My dad had hallucinations in hospice as well, due to Ativan. We requested no more Ativan, and the hospice doctor told us sometimes we had to do things we didn’t want to do. I asked him point blank away from my mom, and he said, yes, they were still giving dad Ativan, despite dad’s and our wishes.

“Fortunately, it was put in his chart, and the nurses refused to give it. Dad was able to spend much more coherent time with us than the doctor expected, thanks to those nurses.”

Donna experienced long-term consequences:

“During a hysterectomy in ’04, the doc ‘accidentally nipped a vessel’ and I lost a lot of blood and needed massive transfusions. The doctor told me this when he came in after the surgery to speak to my husband and me. As a result of the blood loss, I experienced permanent vision loss when the optic nerve in my left eye collapsed, and severe anemia for weeks afterward.

“A year or so later I began to experience chronic urinary tract infections [UTIs] which I’d never had a problem with at all before. In ’08, after many courses of antibiotics for UTIs, a urologist looked into my bladder and found what appeared to be three growths. He operated to biopsy and/or remove the ‘tumors’ but instead found 3 metal staples embedded in the bladder wall.

“They’d been collecting bacteria and were pretty gross. The urologist/surgeon removed them and I became symptom free — no UTIs for a while. The staples must’ve been left by the gyno surgeon in ’04.

“This Nov. after another couple of years of UTI’s and many more courses of antibiotics, I passed a stone after much vaginal bleeding. The urologist again found a metal staple had apparently migrated to my bladder wall, and a stone had formed in my bladder.

” I know that my records from the gyno surgeon do not mention the nipped vessel, the blood loss, vision loss or anemia. I also got a copy of the surgeon’s notes since I’d been told that everyone in the operating room during my surgery had to sign off on those notes, so they would contain all that happened — and they did not tell all, although everyone apparently did sign off on them.

“Once again I’m now symptom free in terms of UTIs, however I have no idea how many more staples I have inside — or where they are…

“The total lack of accountability makes me mad/sick. How can this surgeon continue to practice and never acknowledge his mistake.  How many more mistakes has he been allowed to make with no consequences?”

Preventing Medical Mistakes:

It doesn’t have to be this way. The Agency for Healthcare Research and Quality (AHRQ) reported the results of a study in the New England Journal of Medicine. This research evaluated the benefit of checklists during surgical crises. We’re talking about such events as the one Donna describes above, ie, a severe bleeding episode.

Other such events include cardiac arrest [when the heart stops beating regularly] or a life-threatening allergic reaction. In the middle of a surgical emergency some health professionals may panic or forget proper procedures.

Checklists Work!

In this randomized controlled trial the researchers created a number of simulated crises. In some cases the OR teams followed a checklist while in other situations they tried to do the right thing based on their instincts or memories. When the teams used a checklist they were 75% less likely to delay or miss a life-saving step.

Most revealing of all, after participating in this experiment 97% of the health professionals involved admitted that if they themselves needed surgery sometime in the future they wanted the OR team to employ a checklist if something bad happened. That seals the deal for us!

Protect Yourself From Medical Errors

Next time you have to have surgery, you might ask the surgeon, anesthesiologist and any other members of the team if they could employ a surgical checklist if anything goes wrong during the surgery. Ask if they would consider reviewing the New England Journal of Medicine article before your procedure so that they would know more about the benefits of such a checklist. Any physician with access to The New England Journal of Medicine (and that should be all doctors) can find the “Crisis Checklist” in the Supplementary Appendix to the online article. It should be kept in readily accessible places in the OR!

Images of instruments left behind by surgeons can be found at this link.

Have you ever experienced a medical misadventure? How did you handle it? Would you like to learn more about how to avoid mistakes in the hospital or in the doctor’s office?

You will find our top questions to ask your doctor before agreeing to surgery on page 177 of our book, Top Screwups Doctors Make and How to Avoid Them. You will also learn about the Top 10 Tips to Stopping Screwups in Hospitals and the Top 10 Questions to Ask to Reduce Diagnostic Disasters. Here is a link to the paperback edition of our book.

We hope this book will reduce not only hospital errors but many medication mistakes. Take a moment to read the reviews by readers to see why this book might save your life or the life of someone you love.

How To Prevent Surgical Mistakes:

Do you think you would be brave enough to mention a crisis checklist to your surgeon before an operation?

Have you ever experienced a surgical misadventure? What about a medication mistake?

We would like to hear your answer to our question or your story below. Please comment and let others benefit from your experience.

Revised 4/5/18

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    About the Author
    Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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    After undergoing what was to be “routine” abdominal surgery which turned into a major surgery to get my guts back into place and sewed up correctly, I was moved to my recovery room and given the hand held pump for pain excruciating post-op pain. After two hours I was in complete agony and kept ringing for the nurse who kept telling me that it’s normal to have pain after surgery and to continue using the hand help pump to administer my pain med. Finally I could take no more and lay writhing in pain begging the nurse to knock me out the pain was so bad.
    Long story short…………… the hospital provided me with a faulty pump that did not work and for two hours post-op I was labeled a “complainer.”

    This is one more example of why patients need an advocate.

    65 years ago I gave birth to my first child at an Army Hospital. After not have a period after 2 months, I went to my physician who discovered several cotton swabs were left in me. I had many female problems afterwards.

    One thing about lawyers: You have to be GOOD AND SERIOUSLY INJURED before they’ll take a case, no matter how obvious or flagrant the surgical error. Why? Because otherwise the case won’t pay them enough to make it worth their while. And if it’s anything about eyes, you really kinda have to end up blinded. Several lawyers told me that directly.

    Some years ago I had to have cataract surgery (I got medication-induced cataracts over a 6-month period; no relief there either!). Long story short, the doc put one lens in wrong, and he simply would not admit it. The upshot is that the edge of the lens was in front of my field of vision, resulting in reflections and rays and all kinds of pieces of light emanating off any actual lights at night, and a pesky double-vision thing, even in the daytime, when viewing anything with high contrast (e.g., black against white). I finally went to a different ophthalmologist who IMMEDIATELY said, “well, the lens is out of place!” And this was only 2 weeks after my last visit to the 1st doctor, who swore it was just “nerves.” Can you believe it?!?! I then went to a THIRD doctor, who said, “the lens is quite obviously out of place!” It had been out of place since it was put in.

    The first doctor never admitted to any mistake, and hasn’t to this day. And I still live with the lights and double-vision, because both drs #2 and #3 said it was too risky to do more surgery, that it might make things worse. I contacted several lawyers, aiming to sue the pants off that guy… but not a one would take my case. They said if I was actually left blind, then we could sue for some “real money.” But otherwise, and ESPECIALLY in the case of EYES, the necessary legal research would cost $$ more than any damages they could get. Now how about THEM apples?

    I had laparoscopy by my belly button to check on my tube. They gave me iv to put me sleep but it knocked my lungs first while I was still awake. I could not breathe & I tried to tell my dr that I cud not breathe but i cud not move my mouth, my arms but i did shake my legs to tell them but thanks goodness, it finally knocked me off to sleep. after that @ recover room, I told nurse what happened & she said nothing.

    Anyway, I was traumed with mind crazy with bad experience for a while, finally, no more bothering on my mind crazy with that bad experience. I asked dr for the name of IV numerous times & finally got 4 iv drugs to add my medical history records to avoid those.

    Add this one to mine. In 1981, I had a hysterectomy. The doctor said he’d leave it up to me whether to remove the ovaries or not. He said he preferred to remove them because it prevented future ovarian cancer. But after research on how often that happened, I said to leave them in.

    Fast forward 25 years, some problems necessitating scans, they determined the surgeon DID remove the ovaries, contrary to my wishes. No wonder I had such problems with hot flashes and others.

    The nurses put the GI tube down my Dad’s lungs instead of his stomach so he got meds shoved into his lungs for about 24 hours before they discovered their malpractice. The first thing the doc said when we arrived in the ICU was, “Does your Dad have a Living Will?” I said, “No way! So you’re not going to get away with finishing him off! My Dad had to spend 3 weeks in Rehab to survive. We didn’t sue but should have.

    In July 2016 I went to a well-known hospital in Baltimore. I had a triple by-pass and was in hospital about a week, then went into re-hab for about 6 weeks. While in by-pass surgery the/a surgeon somehow damaged the nerve to my left diaphragm. After weeks of struggling to breath it was found that that lung was not working because the diaphragm is paralyzed. Then it was found that I have pulmonary fibrosis in my lungs because my cardiologist had prescribed amiodarone. So I came out in worse shape (I feel) than went I went in for surgery. Would never have by-pass surgery again.

    I was having 6 levels of steffee plates and screws removed from my Spine. I woke up during the surgery, and I could see the Anesthesiologist through a hole in the operating table. The pain was a 10++++++++.
    The doctor under the table said,”SHE’S AWAKE”. When I saw my doctor, I asked him what happened to me as I woke up during the surgery. He said that we don’t usualy mention it if the patient doesn’t remember it. I told him the pain was awful, and I could hear Mozart in the OR.
    Then later the Anesthesiologist came to my room, and asked me if he sent me some paper work, would I write up what happened to me when I woke up during surgery. A group of Anesthesiologits were writing a book on patients that wake up during surgery. Evidently it happens quite often. But to top it off, he left a lot of the metal in my Spine, and it is still in me.
    God bless, Fonnie

    Hi, I was having six levels of Strykker hardware in my Spine, and I was face down on the table. I could see the Anesthesiologist under the table. I was put to sleep, and I woke up !!!!! I didn’t have patches on my eyes, and I was blinking like mad to get his attention. It was pain beyond words, and it felt like an Elephant was standing on my back. Finally the Anesthesiologist said,” SHE’S AWAKE”. Then I was put back to sleep.
    When I saw my doctor, I asked him what happened? He said what do you mean? I said I woke up during the surgery, and it was not fun at all. He replied we usually don’t tell the patient if they don’t remember it. I told him that I was awake long enough to know that it was tremendous pain, and I could hear Mozart in the background. Later the Anesthesiologist came to my room and asked me if I would mind if he sent me a letter about waking up during surgery, as a group of Anesthesiologists were writing a book about patients who wake up during surgery. I answered the letter in detail. But, it is something that I would never want anyone to go through.

    I know that this is a serious subject but I have a story that is somewhat different and I think you will find to be very funny. A couple of years ago my wife had gallbladder surgery. Before they did the surgery they did the scope procedure to see just how bad things were. They gave her anesthesia for the procedure. I sure would like to find out what they used for anesthesia during that procedure! When she came back to her room, she was as horny as the day is long. I’m serious, she wanted to “do” it right then and there. She didn’t care who was around or that she had a tube coming out her side. If I ever find out the name of the anesthesia, I’m going to buy a train car load of it! LOL
    (And, NO, I did not oblige her desires) :)

    I was an RN who worked in surgery and everything is counted at a minimum of two times sometimes more often, depending on the procedure. The scrub & circulating nurses do the counts even if it slows up the surgeon, he has no choice in the matter. That said, hospitals and their staffs are not what they used to be so patient beware. Never go alone either.

    Seven years ago I fell and dislocated my shoulder joint and as I learned later had a pinched nerve in my spine. The ER doctor told me to see an orthopedic surgeon and have him check me out.
    I called my internist’s office and asked for a recommendation. They gave me the first name on their list. This doctor had an MRI done. Meanwhile my back started giving me fits. The surgeon assured me that he could fix it.
    When I woke up from surgery, I had no bladder or bowel control, and had ten hammertoes. My toes were straight before surgery but curly afterwards. I also had a very bad reaction to the morphine he gave me. The surgeon claimed the hammertoes were from neuropathy.
    Seven years later, I can’t walk without a walker, have had almost constant bladder infections to the point that I now wear a catheter all the time, and have had another surgeon go in and clean up what the first surgeon did. Oh, and I still have the hammertoes which require special shoes.
    Yet no lawyer would take the case because it wouldn’t pay him enough to make it worth his while and no doctor ever indicated that the first surgeon had done anything wrong. I tried to find out where to report this to a medical board or anybody who would listen to no avail.
    I have since learned of other patients who received the same lack of care. My only recourse is to tell anybody who asks why I’m in the shape I’m in and I do. Probably won’t help but makes me feel better.

    To CBI: Unfortunately, you are right that in cases of medical malpractice there is often no one to turn to but a lawyer. There is a widespread “white coat conspiracy” among doctors and hospitals that will thwart efforts at arriving at the truth of what happened.
    When my father died in the coronary care unit as a result of neglect, ignorance and malpractice, I was forced to hire a lawyer to compell the doctors and hospital involved to “fess up.” It was difficult to find a lawyer to take the case – my dad was 70, and in NY, because of caps on awards, the return on the lawyer’s investment of time would be minimal.
    I finally did find one, an ambitious but inexperienced junior member of a firm, and basically outlined his whole case for him (I am a physician) and assisted him in depositions. I made it clear that my intent was to get to the truth and expose culpable individuals.
    He then went behind my back and negotiated a settlement (for much less) between my mother (who by law had to bring the lawsuit) and the hospital, making it impossible to accomplish my goal. It was painfully clear that the lawyer was more intent on getting his whopping cut for as little time and effort as possible.
    And worst of all, the involved parties were allowed to go on practicing medicine with no blot on their records and no accountability. This sordid descent into the world of malpractice law has scarred me for life.
    The victims of medical malpractice rarely get justice or the truth. But lawyers get rich no matter what. Perhaps your husband was different, but he would have been a rarity.

    Several years ago I had an endoscopy, in which a tube with a tiny camera was inserted into my nostril, down my esophagus to evaluate the operation of the sphincter at the opening to the stomach. I was placed under a supposedly mild anesthetic.
    Before the procedure, I had warned that I am very susceptible to anesthesia. When I awoke, I was not advised of any difficulties, but that night I had pain in my chest and discovered a deep purple bruise about 4″ X 2″ between my breasts.
    I confronted the physician, whom I never met before the procedure, on the phone and he casually stated that he had some difficulty bringing me around. I was outraged that this was not disclosed to me. Nor does it appear in the medical record of the procedure nor the info he forwarded to my primary physician. The bruise lasted a week, indicating he really had to thump my chest to resuscitate me.
    This experience, coupled with previous anesthesia results, discourages me from any but the most necessary surgical procedures, not only because of the possible drug reactions but also because of the cloak of silence over the process of the procedure and its possible mishaps.

    Re gauze and instruments being left inside patients after operations. At our hospital in Southern Africa, the scrub nurse RN in charge was responsible for an absolutely accurate count. NO surgeon was allowed to close the wound until she gave her permission that her instrument/swab count was 100% accurate. Surgeon and RN signed the postop notes to this effect.
    A simple but highly effective check

    Hearing stories from friends, personal experience and reading about dangerous bogus drugs and horrible surgical malpractice, I wonder if more people are dying from medical treatment than from illness.
    PEOPLE’S PHARMACY RESPONSE:
    You are not far off Barbara. We document the fact that health care harm (iatrogenesis) is likely the leading cause of death in America. You can find the documentation behind such a radical statement in our book, Top Screwups Doctors Make and How to Avoid Them:
    https://www.peoplespharmacy.com/topscrewups-pp/

    TO CBl, well with the NEW LEGISLATION many of us with no health insurance WILL be covered. And yes, some people blame lawyers for things that are out of their control. And yes there are many more mistakes doctors and hospitals -intentionally or not- make on patients that we know or are reported.

    As much as people criticize lawyers, there is no one else to turn to when things like this happen.
    I fear that an unintended consequence of our new health legislation will be more mistakes and law suits. Then, when the legal expenses rise, the public might be led to believe that “the lawyers” are causing health costs to rise (that’s already a common belief) and that lawyers–not the heath care system—are to blame.
    My husband practiced law for several years, and saw examples of innocent people suffering because of mistakes by doctors and hospitals. In our state, juries rarely awarded large settlements, and clients resented paying the lawyer his fee. It is very difficult and expensive to prepare a medical malpractice suit. “Medical Screw-Ups” explain why it’s unwise to blame lawyers for rising health-care costs.

    My mother-in-law (age 80) broke her hip in a fall last year. Despite specific instructions from the family about former extremely adverse reactions she had had to anesthesia, the hospital and doctors used an anesthesia protocol which–to use layman’s terms–made her stark, raving crazy. The psychotic episode lasted over three days, during which she had paranoid and obviously disturbing delusions and failed to recognize her family members. We weren’t sure if we’d ever get her back!
    Fortunately, she eventually emerged from whatever evil Neverland the drugs had sent her to. She was then put on a handful of drugs which, when I got her to change to our family doctor, he went through and, in many cases, tossed.
    This cautionary tale is told to agree with, and underline, the need for family involvement in the medical care of older relatives. It also demonstrates how, even if that happens, the medical profession will often do exactly the opposite of what benefits the individual patient.
    Scary.

    I keep a bag handy in case I have to go to the hospital. It contains my health history, list of current meds, etc. I am printing this article to place in the bag. I definitely will mention a crisis checklist to the surgeon. Thank you for all you do for us.

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