80,000 Surgical 'Never Events' Charted Over 20 Years

A wide-ranging study of the nation's hospitals has found that, while surgical "never events" are rare, they still pose a threat to patient safety and a considerable financial burden to hospitals.

Foreign objects such as towels and sponges are left inside patients' bodies about 39 times a week, wrong procedures are performed on patients 20 times a week, and wrong body site operations are performed about 20 times a week, estimates a study from the Johns Hopkins University School of Medicine. In all, the study counted 80,000 "never event" episodes that resulted in hospital payouts of about $1.3 billion between 1990 and 2010.

Study leader Marty Makary, MD, an associate professor of surgery at the Johns Hopkins University School of Medicine, says he's not surprised by the findings.

"Many surgeons know how easy it is to leave a sponge behind. Sponges will often change colors. They are packed in tightly. We may put in 20 sponges during a case and have to take all of them out. So it is actually not inconceivable that we could leave a sponge behind," says Makary, who is also the author of Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care.

"In the majority of cases nothing happens," he told HealthLeaders Media. "The sponges are undetected, so they aren't even captured in the study we did. There are many more undetected sponges than the ones we measured. We put artificial things in patients all the time, like mesh and prosthetics. The body just incorporates it. It's sterile when it goes in. Sometimes these sponges can get infected or even cause pain, and in those situations it will prompt a scan or an X-ray and it will be discovered and surgically removed."