Count Me In---And Out

I recently read an article discussing, “Never Events.” To my understanding, a never event means that something never happens, such as only having to ask your teenager one time to clean up his room. However, this article discussed errors that should never happen during surgery. Half of these cases involve objects left inside patients. The most frequently forgotten items were gauzelike sponges---not chewing gum or car keys.

Every year, an estimated 4000 cases of “retained surgical items” are reported. The most practical way to tackle this problem would be to update operating room practices. The old fashioned method to avoid leaving sponges in patients is to assign a nurse to count the sponges as they go in, and as they come out. Some hospitals use “counter bags.” That’s not what they call the nurses, but counter bags are like shoe bags that can be hung over closet doors. Every sponge has its own compartment, and if a compartment is empty at the end of the procedure, it’s an Oh! Oh! moment.

There’s lots of activity in an operating room. Often a doctor’s favorite music is played. If he starts singing the song, “1979” by the Smashing Pumpkins, who could blame a nurse for losing count. Also, discussing golf scores might give one pause.

Some hospitals use a more technological approach. Sponges can be tracked through the use of radio-frequency tags called “RF Assure Detection.” Every sponge contains a radio-frequency tag about the size of a grain of rice. At the end of an operation, the detector alerts the team if any sponges are still stuck inside a patient. The RF Assure adds $10 to the cost of a procedure. That is about the cost of a single suture, and cheaper than a Starbucks, 13 shot venti- soy, hazelnut, vanilla, cinnamon, white mocha and caramel coffee.

Another tracking system relies on bar code technology. You will know there is a sponge inside of you when you are asked to lie on a belt at the checkout counter in the grocery store.

If it’s any consolation I can promise that there are some “Never Events”:

Whatever the surgeon leaves inside of you, it won’t be his bill.

An obstetrician has never left a baby inside the mother. Loud screams are always a good reminder that there’s something in there.

It’s doubtable that a plastic surgeon has ever dropped his wedding ring inside an enhanced bosom, because a divorce can be so much more expensive than a malpractice claim. And---

After opening and closing that long umbrella, I doubt if any proctologist would ever leave it open where the “sun don’t shine.”

My solution to the sponge problem is to switch from sponges to my Mama’s matzo balls. They’ll soak up anything, and will be digested a week later.

Esther Blumenfeld (Patients count backwards---nurses shouldn’t do that!)