California health officials rolled out the latest batch of hospital horrors last Thursday, revealing in graphic detail what went wrong and how many patients died or suffered as a result of serious patient care errors.
Just as they've done every three months or so for the last four years, state officials administered a virtual, but very public flogging to a dozen or so healthcare systems for violations or deficiencies constituting an immediate jeopardy to the health and safety of a hospital patient.
Roughly one in five of the 235 incidents documented so far have involved retained cloth, plastic, or metal objects, such as sponges, lap towels, drill bits, retractors or guidewire.
Indeed, the latest batch imposed fines on hospitals where a retained sponge went undiscovered in a patient for two months, another for six months and a third, for four years.
Yes, that was four years.
And in addition to the negative publicity, hospitals are ordered to pay a fine of up to $100,000 for each incident.
The legislation that established these fines—$9.25 million has been assessed to date—directs that they go to a special fund for projects that improve quality and patient safety. But here we see a bureaucratic and budgetary failure.
Often, reporters ask: Why do surgeons keep forgetting to remove these items? And, how does the state put these fines to good use?
There's usually a nervous pause, because after four years, only a small amount has actually been allocated. After years of bickering, two projects are only just getting started.
Lisa McGiffert, director of the Safe Patient Project for Consumers Union, says California should spend the money. "California is a leader in having this kind of a law that requires fines for putting patients in immediate jeopardy, " she says. "This is money that should be used to prevent future deaths and injuries to patients."
As I wrote in a column two and a half years ago, Kathleen Billingsley, then deputy director for the state Department of Public Health, told me the state was going to spend $800,000 on a research project that would get to the bottom of the retained surgical items cause, and find solutions. Catheters, a denture, drill bits, retractors, electrodes, sponges, screws, and tubing, she said, accounted for 18.6% of all adverse event reports at that time.
It's a terrible problem that causes enormous avoidable patient suffering, infections, and years of follow up care for some patients. And then there are the lawsuits.
But there was a catch: the state Legislature would first have to approve the project. With the state budget in perpetual crisis, there have been delays. And more delays. The University of California San Francisco was supposed to get the contract, but for reasons that remain unexplained, that deal fell apart. Then the contract went to researchers at the University of California Davis.
"The contracting issues, for reasons [state officials] would have to explain, turned out to take much longer than anyone anticipated," explains Kenneth Kizer, MD, director of the Institute for Population Health Improvement at the UC Davis Health System and the investigator heading the project.
Once the contract was executed, he says, "It was sufficiently past the date that the project was due to be finished, and we had to get a contract amended to extend the timeline."
Now, he says, a new, $825,000 contract is "in the throes of being executed."
Finally.
It calls for his team to analyze surgical adverse events, including retained items, and figure out why they happen and how they can be prevented.
In the news briefing last Thursday, Debby Rogers, Billingsley's successor, told reporters that retained surgical objects now account for 27% of reported adverse events in California hospitals. Nothing else, except for hospital- acquired stage 3 or 4 decubitus ulcers, which account for 64% of all adverse events, comes close.
"Many of these patients have to return to surgery and face other complications like infections" that result from the body's reaction to metal, cloth or other material," Rogers said.
According to the latest California report, of the total 5,468 adverse events between mid-2007 and mid-2011, 1,154—more than one in five, were mishaps related to surgery and of those, 850 were due to a retained foreign object.
To make matters worse, the numbers don't seem to be going down.
In FY 07-08, 154 surgical items were found in patients. In FY 08-09, 191; in FY 09-10 there were 265 and in FY 10-11, it was almost as high, 240.
Kizer, former director of the National Quality Forum, says the 2.5-year project's scope of work will include an evaluation of whether more objects are being left inside patients, or whether hospitals are just doing a better job of reporting them.
There are other components to the job as well, such as an examination of possible variation in the way regional state licensing and certification offices assess hospital adverse events, creation of a hospital quality improvement collaborative, and establishment of a patient safety advisory committee.
The project will also examine what surgeons should do in cases where it's unclear whether a retained object's removal would be a greater risk to the patient than leaving it in.
"This is a topic of considerable discussion and disharmony in the larger medical community," he says. "Leaving a pair of scissors or forces or gauze is different than having a drill bit break off; it may put the patient at greater risk to take it out than leave it in."
But finding solutions to keep surgical teams from forgetting these items in the first place is key, Kizer says. "We'll try to find everything we can and distill evidence about what strategies clearly work, what appears promising, and we'll cast the net widely," he says.
I'm delighted that reputable quality researchers will seek an evidence-based solution to the nightmare of retained surgical paraphernalia, and I don't think that $825,000 is too much.
But what about the rest of the $9.25 million? True, about $2 million has not yet been paid or is on appeal. But in another six months, the state should have another $2 million or so paid up, and another $2 million assessed. There's a lot of money earmarked for quality improvement and it should be spent.
Apparently, California lawmakers are content to let it sit in some state bank account, awaiting some future healthcare quality crisis to demand that it be used as the law intended.