Judge and Surgical Sponge Postscript: Lawsuit Causes High Tech Solution to Common Surgical Problem

As I reported back in September, Judge Nelson T. Bailey had the misfortune of having a surgical sponge left inside him after surgery. Five months later, his body rotting from the inside, the hospital discovered its error and removed the intruder. And Judge Bailey did what almost any malpractice victim would do: He sued those responsible. But, Judge Bailey, and the hospital, for that matter, did more than involve themselves in litigation. They decided to make a difference.

First, the hospital admitted its mistake and quickly resolved the lawsuit. Judge Bailey praises the hospital for the quick resolution and for using his case as a springboard to finding a high tech solution to preventing a re-occurrence of his nightmarish experience in another patient. The result is the "wand-and-tag system" and Good Samaritan is the second Florida hospital and one of only one hundred in the country to employ the system. Following the Bailey case, Good Samaritan (the hospital where the incident occurred) CEO Mark Nosacka had this to say:

"Judge Bailey’s experience was a wake-up call for us… "After that, we made an organized commitment to never let that happen again."

The system is actually named the Blair-Port Wand; it is the brainchild and product of RF Surgical Systems, Inc.. The system is reusable and costs only $15 per patient. If an RF, specially tagged, sponge is used, the wand, waved over the patient, will beep upon detecting the sponge. This radio-frequency identification system assures that no one is sewn up with those items still inside.

And Judge Bailey couldn’t be more pleased:

"This is a very genuine and significant step forward in terms of patient safety…"

Leaving a sponge or surgical tool in a patient’s body is a common surgical error; research indicates that this happens an estimated 3000 times per year in the U.S.. The typical method of dealing with this potential error is counting. Staff members keep track of the sponges and instruments that go into a patient; they manually count them, repeatedly, during the course of a surgery. These counts are reconciled before closure. Obviously, this system is highly subject to human error. These sponges are colorless and placed in cavities, cracks and crevices of the human body, often camouflaging themselves as parts of the body. Distractions and miscounts also factor into the counting process. The ‘wand-and-tag system’ eliminates the human factor and replaces it with a virtually foolproof, high tech, solution.

So, what caused this high tech, improved patient safety change at Good Samaritan? A medical mistake, a lawsuit (the "wake-up call"), the willingness to admit the mistake, and a pro-patient search for a solution to prevent the problem from ever reoccurring. This is what pro-safety lawsuits do in America: They make the public safer.

Thanks to Judge Nelson T. Bailey for bringing this pro-safety resolution to my attention and thanks to all involved for making all of us just a little bit safer.