Posted on August 2, 2004

L.A. Hospital Staff Failed To Count Surgical Tools After Operations

AP, Sign On San Diego, Jul. 29

LOS ANGELES — Medical staff at Martin Luther King Jr./Drew Medical Center failed to check whether they left instruments inside patients after hundreds of surgeries, according to the county health director.

A metal clamp was found last month inside a patient at the hospital for 10 days, revealing the widespread failure of hospital staff to count surgical tools after operations.

County health director Dr. Thomas Garthwaite said a review of several hundred surgeries performed at the hospital over the last five months showed no documentation of instruments being counted.

Garthwaite said he couldn’t explain why staff violated hospital and industry rules that call for them to count instruments before and after all surgeries.

Studies show that leaving tools inside a surgical patient is rare, occurring in about one in 1,500 abdominal surgeries. But it happened to Jeffery Baber, who had a five-inch clamp left in his body after surgery last month.

Baber, a 42-year-old Compton mechanic, underwent an emergency trauma operation June 22 for multiple gunshot wounds.

An X-ray technician discovered the clamp while preparing Baber for a separate surgery on his leg.

“They did another X-ray and another X-ray,” Baber said. “It showed plain as day, they had one of the clamps just sitting there.”

Dr. Anthony McCloud, the surgeon who first operated on Baber, performed another surgery to remove the clamp, a scissors-like instrument used to cut off blood flow to certain areas.

Baber said he was thankful the error didn’t kill him, and that no one has apologized to him for the mistake.

The clamp error is the latest in a series of patient-care lapses identified in the last year at King/Drew Medical Center, a county-owned hospital in Willowbrook, about 15 miles south of downtown Los Angeles.

Only six months earlier, the health department brought in a crisis team and outside consultants to oversee changes and address systemic concerns about nursing care at the hospital.

Garthwaite said surgeons are ultimately responsible for what goes on in their operating rooms.

Dr. Kenneth W. Kizer, president of the National Quality Forum, a patient safety group in Washington, D.C., said King/Drew may never know how many instruments were left in patients because surgical staff members weren’t following basic rules.