Today, we filed a federal lawsuit in the U.S. District Court for the Southern District of Texas, Houston Division on behalf of a Colorado client who had a whole surgical towel left inside him after a June 14, 2018 surgery at Baylor St. Luke’s Medical Center, in Houston’s Texas Medical Center.
The lawsuit names as defendants both the hospital and Baylor College of Medicine, who employed the principal surgeon and a total of six physicians involved in the procedure. You can read the federal original complaint here.
As with any medical malpractice case that we investigate at Painter Law Firm, we started with hiring top-notch experts to review and investigate what happened. In this case, we retained a registered nurse (RN) circulator (an operating room nurse) and board-certified surgeon.
What went wrong?
According to our experts’ review, the problem in this case starts with hospital leadership, which apparently allowed the stocking, presence, and use of inappropriate towels in the operating room. Our experts explained that the standard care requires using only radiopaque surgical towels in an operating room for a surgery like this.
Radiopaque towels have a marker on them that will show up in an x-ray scan at the end of the procedure. These x-rays are typically done as a way to enhance patient safety. When a hospital uses non-radiopaque surgical towels, though, it renders the x-ray useless.
Both experts agreed that it’s the responsibility of the registered nurse circulator, who is a hospital employee, to keep a count list of every item used in the surgery that’s intended to be removed. The count list is of critical importance to patient safety and includes things like sponges, sharp items, gauze, and surgical towels.
The responsibility to keep up with these items is not exclusively on the nursing staff, though. The standard care requires surgeons and physicians participating in a procedure to make sure that the RN circulator is aware of disposable items that are being used. And, importantly, our surgery expert shared his strong opinion that Baylor College of Medicine’s surgeons and physicians should have never used a surgical towel that wasn’t radiopaque.
When there’s an unintended surgical item is left in a patient’s body, it can act like a magnet for infection. That’s exactly what happened to our client. After he was discharged from Baylor St. Luke’s Medical Center and went home to Colorado, he had to go to a hospital emergency room because of worsening abdominal pain. It was at that hospital they discovered the surgical towel, a smoldering infection, and life-threatening sepsis.
It’s not the first time this happened at Baylor St. Luke’s Medical Center
As a former hospital administrator, I know that leaving an unintended medical device or supply inside a patient after surgery is a sentinel event, meaning one that should never happen. Any time a serious mistake like this occurs, though, hospital leaders should conduct a thorough investigation, including a root cause analysis that determines how it happened and how it can be prevented.
Unfortunately, our client’s bad experience isn’t the only time in 2018 that there was a retained surgical item left in the patient.
The U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services sent personnel to conduct a survey or investigation of Baylor St. Luke’s Medical Center earlier this year. That research led to a 203-page “Statement of Deficiencies and Plan of Correction” report that the federal government completed on April 5, 2019.
Page 73 of the report, which you can view here, references our client’s retained surgical towel on June 14, 2018, along with three other retained surgical instrument incidents. The report says:
• 5/2018: lap sponge
• 6/14/2018: surgical towel
• 7/24/2018: cervical instrument
• 9/2018: the count sheet was revised and mandatory staff education given
Despite these four reported incidents involving unintended retained surgical instruments or supplies, when a Medicare/Medicaid surveyor interviewed the hospital’s quality staff on March 20, 2019, it was uncovered that this issue “was not brought forward as a PI [performance improvement] project and there was no current tracking information on this problem.”
Because of the cushy protections and privileges that Texas law normally provides to hospitals on their quality improvement in committee work, it’s unlikely that we’ll ever know if Baylor St. Luke’s Medical Center and Baylor College of Medicine have undertaken any new preventative measures to keep their surgical patient safe from retained items.
We are here to help
If you’ve been seriously injured because of a surgical or hospital error, then contact a top-rated experienced Houston, Texas medical malpractice lawyer for help in investigating your potential case.