Complications from a retained sponge destroys patient’s college
Published on MagMutual (https://www.magmutual.com)
Complications from a retained sponge destroys patient’s college
basketball plan
By Georgette A. Samaritan, RN, BSN, Appl. Bio, CPHRM
The Case
An athletic 16 year old male presented to the orthopedic surgeon with complaints of left knee pain
following a fall on the basketball court. An MRI revealed left knee anterior cruciate ligament (ACL)
rupture, with possible radial lateral meniscus tear, and lateral collateral ligament (LCL) sprain with mild
residual instability. The patient underwent outpatient surgery. One year and 3 months post surgery, a
retained sponge was removed by a second orthopedic surgeon. Read more…..
Following an accident on the basketball court, this patient was seen in the hospital ED where he was
diagnosed with an acute medial ligamentous left knee strain. He was discharged home with a knee
brace, crutches, an anti-inflammatory medication, and a referral to an orthopedic surgeon.
Two days later, the orthopedic surgeon diagnosed a complete tear of his left anterior cruciate ligament
(ACL). Five months later the patient underwent a left knee ACL repair under general anesthesia. The
sponge count documentation on the operative report was reported as “correct times 2”. Note: Error
rates with current manual counting practices are approximately equal to 10-15%; in over 80% of
retained sponge cases the count has been falsely called "correct". We characterize these cases as
correct count retention cases. These cases are the result of problems with the practice of counting.[i]
At the first post-op evaluation, the patient’s complaints included decreased sensation around the knee,
difficulty sleeping and a dislike of the pain medication. The surgeon noted redness around the tibial
incision. His impression was that the patient had developed a suture abscess or a superficial wound
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Complications from a retained sponge destroys patient’s college
Published on MagMutual (https://www.magmutual.com)
infection. The patient was started on Keflex for the infection, and placed on Ambien for sleep.
A week later the patient was seen by the surgeon’s partner who was concerned about wound infection,
or perhaps an allergic reaction to the surgical pin. There was now drainage from the left knee incision.
The patient refused deep wound cultures. The antibiotic was changed to Levaquin, and the patient was
advised to monitor the wound daily.
Subsequent post-op visits throughout the summer and fall revealed persistent serous wound drainage,
soft tissue swelling and knee instability. An MRI revealed an ovoid medial knee mass with an intact left
ACL graft. The radiologist’s impression was that “given the patient’s history and the appearance of the
lesion, this likely represents an organizing hematoma with a thick fibrous capsule. If there is no other
intervention, then follow-up is recommended.” The surgeon believed the mass to be a hematoma and
advised the patient that this would eventually dissolve. No follow-up study was ordered at that time. At
8 months post-op, the patient reported worsening instability of the knee joint. A rubbery mass continued
to be palpable along the medial tibia. The surgeon noted guarding and an inability to pivot the joint with
distraction. Twelve months post-surgery, the surgeon ordered an x-ray of the patient’s left knee. The
results showed that the mass in his left knee was a retained radiopaque-tagged sponge. The surgeon
further explained that he re-reviewed the previous MRI scan but had been unable to see any evidence of
a foreign body on that study in any sequence.
Three months later, the patient consulted a second orthopedic surgeon who explored the joint and
found a radiopaque surgical sponge, completely encapsulated in abundant scar tissue. Extensive and
careful dissection was required, with more tissue removal.
The plaintiff alleged a delay in treatment, resulting in additional scarring, chronic pain, knee mobility
problems, crepitus and joint instability, with limitation of his choice of future sports and activities. His
plan for a college basketball scholarship could not be realized.
The case was ultimately settled; both the surgeon and the hospital contributed towards the settlement
proceeds.
Risk Management Commentary:
We’re continuing to see claims involving retained foreign objects after surgery. The lingering effects of
such events can be significant for patients and providers.
In this case, the hospital argued that there was no sponge count policy or procedure in place at the time
of the patient’s surgery; therefore the hospital felt that sponge counting was “not their job”. This
defense wasn’t effective in reducing the hospital’s exposure. The three main “stakeholders” in
preventing retained sponges are surgeons [1], nurses [2] and radiologists [3], and communication
between all three is a key element. Surgeons and nurses are the primary defenders against retention;
radiologists are secondary defenders that mitigate harm. There should be an alliance between the
surgeon - whose responsibility it is to remove all surgical items not intended to remain, and the surgical
nurses who are responsible for corroborating or refuting the surgeon’s assessment that everything has
been removed. Preventing retention is a joint and shared responsibility.
Suggestions for Surgeons and Hospitals:
Comply with standardized practices to account for all instruments and items used during surgical
procedures.
Follow policies and procedures governing counts, identifying and resolving discrepancies
immediately, and implementing the other practices to prevent retained surgical items.
Ensure that all sponges and other items used during surgical procedures are x-ray detectable.
Consider using radio-frequency identification (RFID technology), bar-coding or other technology
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Complications from a retained sponge destroys patient’s college
Published on MagMutual (https://www.magmutual.com)
to supplement surgical item counts.
Require that discrepancies be reported to the risk manager
Report any adverse events or near misses related to retained surgical items or count
discrepancies as part of the facility’s event reporting system.
References/Resources:
Association of periOperative Registered Nurses (AORN)
Recommended practices for prevention of retained surgical items. In: 2011 perioperative standards and
recommended practices. Denver (CO): AORN Inc; 2011
[i] NoThing Left Behind®: A National Surgical Patient-Safety Project to Prevent Retained
Surgical Items, http://www.nothingleftbehind.org/Soft_Goods.html [4]; includes “A MultiStakeholder
Prevention of Retained Surgical Items Policy”
The information and resources provided in this course or publication have been prepared to provide
general information only. It is not to be relied upon in lieu of or as a substitute for legal, medical or other
professional advice. The laws, rules, regulations and case law may differ in your state. Please consult a
licensed attorney in your state for specific questions and advice. While all care has been taken in the
preparation of this course or publication, no responsibility is accepted by MagMutual Insurance
Company or the MagMutual Patient Safety Institute or its employees or agents for any errors, omissions,
or inaccuracies, or for any known or unknown consequences that may result from reliance on any
information provided in this publication.
Source URL: https://www.magmutual.com/learning/claimslesson/complications-retained-spongedestroys-patient%E2%80%99s-college-basketball-plan
Links
[1] http://www.nothingleftbehind.org/uploads/Surgeons.pdf
[2] http://www.nothingleftbehind.org/uploads/Nurses_and_Surg_Techs.pdf
[3] http://www.nothingleftbehind.org/uploads/Radiologists_and_Technologists.pdf
[4] http://www.nothingleftbehind.org/Soft_Goods.html
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