A woman in Montréal underwent a total hysterectomy for ovarian cancer back in March, and from the moment she woke up from anesthesia, had shoulder pain “like being stabbed with a knife.” After being told such pain was normal after surgery and eventually having her shoulder x-rayed and injected with cortisone, the real cause was found 2 months later.

When an abdominal x-ray was taken, a 30 cm [about 1 foot] metal retractor was found. The shoulder pain was due to the retractor pressing on the diaphragm. A second operation was required to remove it.

According to a CBC News story about the incident, the hospital where this took place “launched an investigation.” This is, of course, what hospitals do.

Standard procedure in every hospital is to meticulously count the sponges, needles, and instruments used before the case begins, whenever items are added to the operative field, and twice before the case ends. The Montréal hospital staff apparently did so.

The Québec Health Minister said, “Everything is counted and recounted at the end to make sure that nothing stays inside the patient, and in this case it was the recounting process that didn’t work.”

See, the “process” was to blame. I disagree. A major cause of retained objects in surgery is human error—specifically mistakes in counting.

A New England Journal of Medicine study by Gawande et al found “Of the many cases of retained foreign bodies in which counts were performed, 88 percent involved a final count that was erroneously thought to be correct.”

Significant risk factors for retention of a foreign body in the NEJM series included the following:

Even if the first count is correct, most prudent surgeons take a final look around the abdomen to be sure nothing is left behind before closing the incision. Had this been done, the retractor would surely have been seen or felt. When in doubt, an x-ray should be taken to verify that no foreign bodies are present.

A recent literature review said the incidence of retained sponges and instruments after surgery is anywhere from 1 in 5500 to 1 in 18,760 inpatient operations, and surgical sponges are the most common item found. A retained foot-long retractor is unusual but not unheard of. Below is an x-ray from a case report of a similar retractor discovered and removed 14 years after a splenectomy.

Experts and regulatory bodies agree that leaving an instrument or sponge in a patient should never occur.

The hospital’s plan of correction is “Surgical teams have been given a memory aid that has more elaborate counting and recounting procedures for operations to make sure that no medical equipment is left behind.”

The scrub tech and the circulating nurse count all the items together. What could “more elaborate counting and recounting procedures” possibly be?

If that memory aid works—and I don’t think it will—I hope the hospital will share it with us.

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.