Medical errors increasing in Utah

SALT LAKE CITY — Whether it's a sponge, a towel or a surgical instrument, the idea of having surgeons sew up a patient with a foreign object left inside gives plenty of people pause before surgery.

Those kinds of errors were noted 25 times in Utah last year, according to an annual report released Wednesday by the Utah Department of Health.

They were among the 101 "sentinel events" reported by Utah hospitals and surgical clinics as part of the state's effort to monitor, and help correct, medical errors.

There were 21 more errors or mishaps last year than in the previous two years, and 54 of them occurred either in surgery or in procedures that were not performed as specified.

Iona Thraen, patient safety director at the Utah Department of Health, said sponges — large pieces of gauze used to stop or absorb bleeding — are the most common items left inside patients because they can be hard to spot after surgery.

"It's the equivalent of giving you 371 $1 bills in a wad," she said of the sponges, "and soaking them all with blood, then having to count every one of those with the patient lying on the table."

A couple of the foreign objects left in patients were metal guide wires that surgeons use to move through tight spaces that break off inside patients, Thraen said. The health department is most concerned about the objects that are "left unknowingly" rather than those where retrieving the object would cause greater risk or harm to the patient than leaving it, she said.

Other events logged in the report include surgery on the wrong body part, medication errors, pressure ulcers and patient falls.

Deb Wynkoop, director of health policy for the Utah Hospitals and Health Systems Association, said some of the increase in the number of mishaps came as a result of adding three new hospitals and a few new surgical centers within the state in 2009, increasing the number of patients being treated.

The number of errors reported has grown exponentially in the past three years, particularly, she said, as the number of categories that are surveyed for errors increased from eight to 32 beginning in 2007.

She said it's important to put the numbers in context, noting there were more than 152,000 hospital-based outpatient surgeries in 2008 in Utah, and that number rose last year.