After a Fresno, Calif.-based Community Regional Medical Center surgeon put a patient in serious jeopardy by leaving a surgical towel inside his body, the cancer center had to rethink its surgical count program.
CRMC agreed to pay a more than $86,000 fine and implement a plan of correction, according to a report from the California Department of Public Heath.
About one month after receiving surgery on April 8, 2014 for bladder cancer, the patient stated, "I had lost 43 pounds, my bowels were not working right, I had no energy, no stamina and I felt like I might not live," according to the report. The patient added, "I couldn't even drive myself to my doctor appointments during this time, and I could not even walk from the bed to the couch without becoming fatigued."
The operating room team had found the scissor count incorrect post surgery and issued an X-ray of the patient, but found nothing, according to the report. However, at the time, they did not have a procedure in place to count the blue surgical towels, because "the towels are well documented everywhere else and it has always been known by the surgical staff not to use those towels on a patient" a risk manager told the Department of Health.
The towels were not radiopaque, so they were not picked up by the initial X-ray. It was not until the patient saw a third physician for his complications that an abdominal mass was found on a CT scan. In a second surgery, the blue surgical towel was discovered.
The Department of Public Health found the hospital failed to follow its OR counts procedure, which led to the towel being retained in the patient for three months, causing serious injury and putting the patient at risk of death, according to the report.
During a DPH interview with the director of surgical services and the manager of surgical services at the hospital, the officials stated, "This was a lesson learned, the blue surgical towels will no longer be allowed on the surgical field once an incision is made. Only radiopaque towels will be allowed," according to the report.
Immediately after CRMC was informed of the mistake in July 2014, it implemented a towel count program, according to the report. Once a surgery begins, CRMC now requires only radiopaque towels to be used if needed, and the towels are required to be counted, according to the report. By July 15, 2014, an audit found this procedure was being followed 100 percent of the time, according to the report. An additional audit was completed in November 2014, and continued randomly twice a week to ensure compliance, according to the report.
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