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Emergencies, procedure changes contribute to left-behind surgical instruments Pfizer slaps bar codes on unit dose medications Senators balk at Bush's stance on malpractice reform

Patient Safety Monitor Alert, January 17, 2003

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EMERGENCIES, PROCEDURE CHANGES CONTRIBUTE TO LEFT-BEHIND SURGICAL INSTRUMENTS

Surgeons across the country accidentally stitch up about 1,500 surgical tools into patients each year, authors of a new study estimate. Researchers calculated the figure after they reviewed records of a large malpractice insurer representing about a third of Massachusetts' physicians between 1985 and 2001, according to "Risk Factors for Retained Instruments and Sponges After Surgery," an article published in last week's New England Journal of Medicine. They found 61 sponges or instruments in 54 patients.

From those cases, researchers determined that the following factors significantly increase the likelihood of a left-behind sponge or instrument:

- emergency surgeries
- unplanned changes in procedure
- higher body-mass indexes

The patient's sex, involvement of multiple teams with the surgery, amount of blood lost, and changes in nursing personnel were not significantly related to incidents, however. Whether or not someone counted sponges and instruments was a factor according to some analyses, but not others, and after further testing researchers concluded that it was strongly related to whether or not the surgery was an emergency.

PFIZER SLAPS BAR CODES ON UNIT DOSE MEDICATIONS

Medications from Pfizer will soon feature bar codes that--in hospitals with the proper equipment--allow nurses to check a drug's dosage and other features at a patient's bedside before administering it.

The company has already begun printing its miniature bar codes on some if its individual dose, or, "Hospital Unit Dose" packages, and plans to bar code all its individual dose packages by the end of this year. It will add other packaging "as technology permits," according to a press release from Pfizer. Clinicians can read the bar codes with hand-held scanners currently on the market, which can also read patients' identification bracelets to make sure the right patient receives the right medication.

The Wall Street Journal called Pfizer's decision "the most comprehensive by a major pharmaceutical company to make medicines used in hospitals compatible with computerized systems to assure that a patient is getting the right medicine in the right strength at the right time." The U.S. Food and Drug Administration is currently developing a rule requiring all drug manufacturers to bar code individual products, according to the release.

SENATORS BALK AT BUSH'S STANCE ON MALPRACTICE REFORM

President George W. Bush renewed his proposal for capping lawsuits--but even before his announcement, some senators asked him to reconsider. "The best answer to unreasonably high medical malpractice premiums is tougher regulation of insurance companies," U.S. Senators John Edwards (D-NC), Ted Kennedy (D-MA), Patrick Leahy (D-VT), and Dick Durbin (D-IL) wrote in a letter to the president the day before his announcement last Thursday, according to McClatchy Newspapers.

Bush revived a proposal he made last July that would cap malpractice awards for pain and suffering at $250,000 during a speech he made last week in Scranton, PA, according to the Associated Press (AP).

Edwards told the AP that Bush's plan would not reduce doctor's premiums. "The truth is the insurance industry has done poorly in the market and is simply passing those costs on to doctors and patients," he said.

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