In the airline industry they have checklists. In Japan, train operators point and vocalize. In my volunteer fire department, we've adopted a "two sets of eyes" policy on all technical rope rigging before declaring it ready.<p>I know humans are fallable, but I feel like there are some basic, workplace culture driven techniques that could substantially help here.
My mother had rags left in her during a surgery that ended up fucking up the course of her life forever and leaving her permanently disabled. The rags didn’t cause the primary problem, but were just a part of their shoddiness.<p>Of course it’s not every surgeon, but there are some butchers that out happens more with. It ended up being a repeat problem for my mother’s surgeon.
As a comparison in the UK there is robust mandatory reporting on "Retained foreign object post procedure" which is a so-called "Never Event" in the most recent publication (April 2024 to September 2024) this occurred 60 times[1] in the NHS in England. For a denominator there are approximately 21 million operation performed in a year by NHS England[2]. So roughly 0.002% of cases have an unintended retained object or roughly 1 in 50,000.<p>For further reading the Health Services Safety Investigations Body in the UK (like the NTSB but for healthcare incidents is the best worst analogy) looked at retained foreign objects and published in 2024: <a href="https://www.hssib.org.uk/patient-safety-investigations/retained-surgical-swabs/" rel="nofollow">https://www.hssib.org.uk/patient-safety-investigations/retai...</a><p>[1]: <a href="https://www.england.nhs.uk/long-read/provisional-publication-of-never-events-reported-as-occurring-between-april-2024-and-september-2024/" rel="nofollow">https://www.england.nhs.uk/long-read/provisional-publication...</a>
[2]: <a href="https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2023-24" rel="nofollow">https://digital.nhs.uk/data-and-information/publications/sta...</a>
When my wife had some minor surgery (not fully anesthetized), there was a nurse present who counted all of the sponges, etc. that were used, then made sure there were that many on the tray at the end. They didn't match up, and it turned out that the surgeon had dropped one off of the table.<p>The article mentions that counting is standard procedure, so hopefully this is how it works everywhere. It definitely seems like having someone who isn't the surgeon doing the counting would be the way to go. The surgeon is already very focused and it's easier to say "I'm sure I didn't leave anything" when someone else isn't telling you otherwise.
Not all surgeons are alike, just as in any profession: some make many errors and some make few. But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions about their surgical provider, which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market.
Seems there should be a "check in" "check out" list, managed by one of the other staff, and double checked by another, ideally.<p>Or even some form of RFID tagging and a scan wand.
This sounds like the perfect application of image processing and machine learning. A computer with a camera attached could monitor the whole operation and warn the surgeon if it detects an object going in but not out.<p>At least it would be more useful than the system they use for self checkouts at my local supermarket. "Did you forget to scan something in your trolley?" Yes, it's my child.
At least in America, surgeons are part of an entitled medical elite, and there is tragically little interest in holding them to account. Let alone forcing them to do better.