Toronto·GO PUBLIC

More surgical items being left inside patients blamed on rushed operations

A longtime surgical nurse says the rise of of surgical items being left inside patients is because of systemic problems that are causing medical teams to rush through operations.

'I was in constant pain,' says woman who had glove, sponges still inside her

Tracy-Ann Wallace was initially turned away when she complained to her surgeon about her post-operative symptoms, but a medical error came to light when Wallace insisted on an exam. (Jonathan Castell/CBC)

Tracy-Ann Wallace says she'll never forget the sharp pain in her stomach and the putrid smell coming from inside her body after a partial hysterectomy.

"I was in constant pain and I had problems going to the bathroom," said Wallace, 47 who had the surgery at St. Michael's Hospital in Toronto in 2014, after developing uterine fibroids.

The 47-year-old says her doctors told her the problems were part of routine healing, but as the weeks passed, the pain and smell got worse.

Finally, a friend convinced Wallace to show up at her surgeon's waiting room, and just sit there until the doctor agreed to see her.

When the surgeon finally examined Wallace, the problem was apparent and "horrifying." 

"She put her gloves on and reached in and took a glove and two sponges out of my body," said Wallace.

Need for speed

As Go Public recently reported, the number of objects being left in patients after surgery in Canada has jumped 14 per cent over the last five years. 

That's no accident, but a systemic problem caused by doctors and nurses being pressured to rush through surgeries, according to veteran surgical nurse Bev McLean. 

McLean has spent more than half of her 33-year career in operating rooms, as a nurse, among other positions, and, most recently, reviewing operating room mistakes for legal cases.

She says Wallace's story reminds her of a case she reviewed in 2010. In a rush to finish an operation, a surgeon grabbed a sponge from the instrument table after a nurse had finished counting medical devices to ensure all were accounted.

The sponge was lost in the count and left inside the patient. It was only discovered after he developed a painful infection and required another surgery to be removed, says McLean.

In an effort to reduce wait times and cut costs, many provinces cap funding for certain kinds of surgeries, no matter how complicated or what problems arise.

At the same time, the provinces require hospitals to balance their budgets, resulting in a crackdown on overtime and adding to the pressure to rush through surgeries.

Bev McLean, a nurse for 33 years, says surgery errors are the result of several problems in the health-care system.

"There's a big push these days to be fast," McLean told Go Public, "and that's part of the problem. The faster you go in any procedure, no matter how good you are as a team, there's always the risk that you're going to take a shortcut or that you might miss a step, or you're doing two steps at the same time."

The Canadian Nurses Association and the Operating Room Nurses Association of Canada say they too see this as part of the problem.

Asked what it's doing about the problem, Health Canada said in an email "the practice of medicine" is up to the provinces. 

There are oversights and safety measures in place. Accreditation Canada, an independent agency that sets standards for publicly funded hospitals, made it mandatory in 2011 for surgical staff to count the devices — sponges, needles, clamps, scissors, etc. — used after a procedure to ensure nothing is left behind.

This kind of medical mistake is considered a "never event," meaning there are enough safety measures in place that it should never happen. But despite that, it does.

Alberta and Quebec have the highest rates of leaving foreign objects inside patients, according to a study from the Organization for Economic Co-operation and Development (OECD). 

Both are above the national average of 9.8 such mistakes per 100,000 patients: Alberta at 12 and Quebec at 15 per 100,000 patients.

A spokesperson for Quebec's Ministry of Health and Social Services tells Go Public, such "omissions remain very rare," adding operating room staff need to be vigilant and follow best practices.

Alberta Health Services recently finished a comprehensive review of what's causing these errors, and found the "primary factors identified are distractions, incorrect surgical tool counts and challenges with surgical team dynamics," according to spokesperson Kerry Williamson.

Williamson says there is no single, identifiable reason why Alberta's rates are higher, but that it's likely due to the province's good reporting system.

In Ontario, hospitals are required to report to the Ministry of Health on their use of the instrument checklist — which has shown to "reduce the rates of death and complications," according to ministry spokesperson David Jensen. The ministry noted the province's rate of left-behind medical devices is lower than the national average, but would not comment on whether the funding model or the pressure to balance hospital budgets is leading to rushed operations. 

'Black box' recorders

In some parts of Canada, including Toronto and Ottawa, evidence about medical errors is being gathered in operating rooms equipped with "black box" recorders, similar to those in airplanes, providing a window on what can go wrong.

The boxes include cameras and microphones that monitor what's being said and done in operating rooms, analysis of which shows distractions like loud noises, irrelevant conversations and doors opening and closing may be leading to medical mistakes. The Toronto doctor behind the project, Teodor Grantcharov, has been testing the boxes for almost four years. 

Noises distracted surgeons a median of 138 times per surgery according to findings released in June 2018. 

Surgical instrument counts were made mandatory in Canadian public hospitals in 2011, yet the error rate has continued to climb. (CBC)

Misplaced medical devices are part of the broader problem of "preventable patient harm incidents" — a category of mishaps that also includes hospital-acquired infections, blood clots and childbirth trauma. 

Those mishaps are part of a "silent epidemic," according to advocate Kathleen Finlay, founder of the Center for Patient Protection, an independent,Toronto-based group aimed at improving health care.

"People are being injured, permanently disabled and even dying … so the federal government needs to treat this as the public health-care crisis it is," said Finlay.

And when it comes to such incidents, Finlay says the future looks grim, based on a 2017 report from the Canadian Patient Safety Institute, a not-for-profit health-care watchdog. 

The report found more than 12 million Canadians in hospital and home-care settings will be harmed by the healthcare system over the next 30 years, costing the health-care system an additional $2.75 billion per year.

Another 1.2 million people will lose their lives. 

So what can be done?

Finlay would like to see those black boxes routinely used in operating rooms across the country. She's also calling on the federal government to create an independent organization that would investigate hospital medical errors and wants Canada to implement a national hospital rating system, like those in the United States.

She also wants to see provinces standardize what data is collected and reported about medical errors so Canadians have a clear picture of what's happening.

"They're very different from one province to the next," she says. "So they're really not the kind of numbers that give you a full picture."

Kathleen Finlay of the Center for Patient Protection is calling for more transparency about medical harm incidents, including black box recorders in surgeries and mandatory public reporting of medical errors. (Kathleen Finlay)

Tracy-Ann Wallace, the former patient, says she was shocked to learn how many patients have had the same — or similar — experiences to her own.

In her case, the surgeon apologized, telling her it shouldn't have happened. Yet, five years later, she's still wondering how it did.

"This doesn't need to be happening and it shouldn't be happening. We need to tend to it," she said.

St. Michael's Hospital tells Go Public it reviewed what happened in Wallace's case and the results led to changes that strengthened its process for counting equipment at the end of a procedure. 

About the Author

Rosa Marchitelli is a national award winner for her investigative work. As co-host of the CBC News segment Go Public, she has a reputation for asking tough questions and holding companies and individuals to account. Rosa's work is seen across CBC News platforms.

With files by Jenn Blair

Comments

To encourage thoughtful and respectful conversations, first and last names will appear with each submission to CBC/Radio-Canada's online communities (except in children and youth-oriented communities). Pseudonyms will no longer be permitted.

By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Please note that CBC does not endorse the opinions expressed in comments. Comments on this story are moderated according to our Submission Guidelines. Comments are welcome while open. We reserve the right to close comments at any time.