Correspondence

Risk Factors for Retained Instruments and Sponges after Surgery

N Engl J Med 2003; 348:1724-1725April 24, 2003

Article

To the Editor:

In explaining the association between increased body-mass index and a higher risk of retention of a surgical instrument or sponge, Gawande et al. (Jan. 16 issue)1 suggest that the increased risk may reflect “the amount of room there is in a patient in which to lose a sponge or instrument.” A number of equally good explanations exist. Overweight patients, for some reason, may not get the surgeons they deserve. Increasing obesity may increase the technical difficulty of the operation, and this may place more stress on the surgeon. Increasing patient bulk, attendant illnesses, and fear of postoperative complications may subconsciously cause operations to be rushed.

This study concentrates on factors pertaining to the operation rather than the operator. We know nothing about the surgeons, including their ages, their positions on the procedural learning curve, their involvement in any past malpractice claims, and their attendance at morbidity and mortality reviews.2 Also pertinent is operator fatigue, including workload, downtime (especially regular vacations), and number of sites of employment.

Richard T.L. Couper, M.B., Ch.B.
University of Adelaide, Adelaide 5006, Australia
richard.couper@adelaide.edu.au

2 References

1. 1

   Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229-235
   Full Text | Web of Science | Medline

2. 2

   When doctors make mistakes. In: Gawande A. Complications: a surgeon's notes on an imperfect science. New York: Metropolitan Books, 2002:47-74.
   

To the Editor:

In 11 of the 54 patients described by Gawande et al. as having retained foreign bodies after surgery, the procedure was repair of an episiotomy or vaginal tear. Episiotomy repair is performed mostly by one person in a room that is not a surgical theater. The operating conditions are often suboptimal because of bleeding, poor lighting, and inadequate analgesia. It is considered a minor procedure and is often delegated to the most junior member of the team. Midwives and doctors involved in carrying out this procedure have often not received any formal training about the technique or about the need for counting instruments and swabs before and after the procedure. A recent survey of obstetrical programs in the United States showed that 60 percent of residents had not undergone any formal teaching on episiotomy-repair techniques or pelvic-floor anatomy.1

Gawande and colleagues correctly point out that this is likely to be the tip of the iceberg. Adequate procedures must be established to facilitate risk analysis and management.

Narendra Pisal, M.D.
Michael Sindos, M.D.
Gaye Henson, M.D.
Whittington Hospital, London N19 5NF, United Kingdom
pisal@dr.com

1 References

1. 1

   McLennan MT, Melick CF, Clancy SL, Artal R. Episiotomy and perineal repair: an evaluation of resident education and experience. J Reprod Med 2002;47:1025-1030
   Web of Science | Medline