IHP 430 Module 1 Medical Error Short Paper example

A Sponge After the Cesarean: A Retained Surgical Item Analyzed as a System Error

[Student Name]

Southern New Hampshire University

IHP 430: Healthcare Quality Management

Module One Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

A Sponge After the Cesarean: A Retained Surgical Item Analyzed as a System Error

The Event

A 31-year-old woman in her second pregnancy arrived at a composite community hospital's labor unit at 39 weeks and went to an emergency cesarean birth at 02:40 after a prolonged fetal heart rate deceleration. The operation began 11 minutes after the decision. Blood loss was estimated at 1,400 milliliters, a second attending obstetrician was called in to help control bleeding from the uterine incision, and the circulating nurse, who had also been covering a second laboring patient, handed off to a relief nurse during closure. The final count was recorded as correct. The patient went home on the third day with a healthy infant.

Twenty-two days later she returned to the emergency department with fever, abdominal pain and a tender mass. Computed tomography showed a radiopaque marker consistent with a retained laparotomy sponge surrounded by an abscess. She underwent a second laparotomy, a four-day admission and two weeks of antibiotics, and she missed the first month at home with her newborn. The hospital disclosed the error to her the same day, reported it to The Joint Commission as a sentinel event and began a root cause analysis.

Classifying the Error

The Institute of Medicine defined an error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (Kohn et al., 2000). The plan in this case was correct: count every sponge in and out and remove every one. The failure was in execution, which makes this an error of execution rather than of planning. It also caused harm, so it is a preventable adverse event rather than a near miss. Unintended retention of a foreign object is one of the National Quality Forum's serious reportable events and one of the sentinel events The Joint Commission reviews most often, and reports to its database show that sponges are the item most often left behind (Steelman et al., 2018).

Classification matters because it decides the response. A near miss invites a conversation; a sentinel event requires a comprehensive systematic analysis, an action plan and measurement of whether the plan worked. It also locates the problem. The count was recorded as correct and still missed the sponge, which tells the reviewer at the outset that the answer will not be found only in the nurse who signed the count sheet.

Active Failures and Latent Conditions

The model of human error described by Reason (2000) distinguishes active failures, the unsafe acts of people at the sharp end, from latent conditions, the gaps built into a system by decisions made far from the bedside. The active failure here is plain: a sponge was not seen and the count was reconciled anyway. Treating the event as that alone would produce retraining and a warning letter and would leave every condition that set it up in place.

The latent conditions are more instructive. In a case-control study of malpractice claims, Gawande et al. (2003) found that retained items were far more likely after emergency surgery (risk ratio 8.8) and after an unplanned change in the procedure (risk ratio 4.1), and that risk rose with body mass index. This case carried two of those three risks: it was an emergency, and the bleeding turned a routine closure into a longer operation with a second surgeon. Steelman et al. (2018) reviewed 319 retained sponge events reported to The Joint Commission and found that about a third occurred in labor and delivery, where sponges are also used for vaginal births, and that human factors and leadership were the most frequent contributing categories. A nurse covering two patients at night, and a relief nurse taking over a count mid-closure, fit that pattern exactly.

The last latent condition is the reliance on counting itself. Cima et al. (2008) reviewed four years of events at one academic center and found that in 62 percent of actual retained objects the count had been recorded as correct. A count is a human check performed under the same pressures that produce the error it is supposed to catch. A hospital that has no backup to the count, such as radiofrequency detection or a policy for imaging after emergency surgery, has accepted that some sponges will be missed.

Which Dimensions of Quality Failed

The six aims for improvement ask that care be safe, timely, effective, efficient, equitable and centered on the patient (Institute of Medicine, 2001). The event failed safety directly, because the patient was harmed by the care meant to help her. It failed efficiency, since a second operation, an admission and antibiotics consumed resources that added nothing. It also failed patient-centeredness in a way the chart does not record: a new mother lost weeks of recovery and bonding with her child. Timeliness suffered as well, in a quieter way: the diagnosis took three weeks because nothing at discharge prompted anyone to look for a retained item, and she returned sicker than she would have been with an earlier scan. Framing the harm across several dimensions shows leaders that a retained sponge is not a narrow surgical matter but a failure of the organization's promise to patients.

Preventing the Next One

Three changes follow from the analysis, listed from strongest to weakest. First, add a technology backstop to the count: radiofrequency-tagged sponges and a wand scan before closure in every operating room and every labor room, which does not depend on attention at 3 a.m. Second, make the handoff safe: prohibit a change of circulating nurse during closure except in an emergency, and when it happens, require a full recount with both nurses present. Third, require intraoperative imaging before the patient leaves the room when an emergency operation has a count discrepancy or an unplanned change. Retraining alone is the weakest action and should support these, not replace them. Each change should be measured, for example through the rate of count discrepancies and the proportion of emergency cases scanned, so the hospital knows whether it worked, and reported to the surgical quality committee each quarter alongside the number of sentinel events, which should be zero.

References

Cima, R. R., Kollengode, A., Garnatz, J., Storsveen, A., Weisbrod, C., & Deschamps, C. (2008). Incidence and characteristics of potential and actual retained foreign object events in surgical patients. Journal of the American College of Surgeons, 207(1), 80-87. https://doi.org/10.1016/j.jamcollsurg.2007.12.047

Gawande, A. A., Studdert, D. M., Orav, E. J., Brennan, T. A., & Zinner, M. J. (2003). Risk factors for retained instruments and sponges after surgery. New England Journal of Medicine, 348(3), 229-235. https://doi.org/10.1056/NEJMsa021721

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academies Press. https://doi.org/10.17226/9728

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768

Steelman, V. M., Shaw, C., Shine, L., & Hardy-Fairbanks, A. J. (2018). Retained surgical sponges: A descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Safety in Surgery, 12, Article 20. https://doi.org/10.1186/s13037-018-0166-0