The Folly of Ordering, Then Ignoring, Radiographs
A 58-year-old woman with severe colon inertia developed an anastomotic leak after surgery to remove a dead spot on her colon. After several unsuccessful surgeries, the patient underwent a 17-hour laparotomy. As the physician was getting ready to close the incision, the scrub nurses told him that the sponge count was off and that one was missing. The physician ordered a radiograph, but before he looked at the results, he found what he believed to be the sponge and removed it. However, the radiograph actually showed that 2 sponges had been left inside the patient.
Over the next 2 months, the patient had further surgeries to correct a fistula which kept opening. Eventually, the physician looked at the radiograph from the 17-hour surgery and realized that a sponge still remained in the patient. The physician told the patient and her husband about the sponge but indicated to them that it wasn’t causing any problems at this time. A few months later, the patient developed an infection that the physician suspected was caused by the sponge.
Two unsuccessful surgeries were conducted to attempt to remove the sponge, but the patient’s spleen was injured during one of the surgeries and the sponge was not removed. A year later, after undergoing an unsuccessful bowel transplant, the patient died due to multiple organ failure.
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Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association and editor of Pharmacy Times.