A patient has died in California after surgeons at Mercy Medical Center Redding left a sponge in their abdomen, a California Department of Public Health report reveals.
The patient - whose name and gender are unidentified in the report - underwent surgery to bypass a blocked blood vessel in his lower abdomen.
It's a fairly low-risk, although serious procedure, but for this patient, a miscount of surgical sponges proved fatal.
The forgotten sponge caused an infection in the patient's abdomen and they suffered a heart attack before dying of the infection 10 days after the operation.
Surgical sponges are the most common items to be left in patients' body cavities during operations.
In fact, surgical objects are left inside some 1,500 patients, according to a 2007 study - and about two thirds of those are surgical sponges.
As was the California patient's case, sponges are most commonly dropped, lost, forgotten or abandoned in the abdomen.
Sponges are important tools for surgery, as they allow the operating team to soak up blood and other bodily fluids to keep their field of vision clear and as clean a possible while they work.
Sold in different sizes depending on where and how they are intended to be used, surgical sponges are typically made out of cotton gauze, or sometimes gelatin foam.
They come in sterile packaging, but left in a body cavity, soaked in blood and other bodily fluids, sponges quickly become fertile breeding grounds for all manner of bacteria.
For this reason, if you were to stand in an operating room, you would hear at various points before during and after the surgery, the circulating nurse - who assists with the surgery but stays out of the sterile area - and the surgical tech (who directly assists the operating physician) will sound off in rounds of counting.
Before surgery begins, they and the surgeon decide how many of each sterile tool and object will be required, and as they use, remove and dispose of these, the pair has to count them out and make sure that all items are accounted for at all times.
The final number of sponges, sharp objects and other surgical tools accounted for in the end must be exactly the same as they were at the beginning.
At Mercy Medical Center Redding, the guidelines also hold the surgeon responsible for overseeing this process, according to the surgical center's guidelines.
The chart from the the procedure showed that the count of sponges had matched at its beginning and end.
The scrub nurse who was half responsible for the count swore that all of the lap band sponges they'd started surgery with had been there, a fact she confirmed with the circulating nurse.
Mercy Medical Center uses bags with 'holder pockets' for each sponge to make sure they're properly counted and disposed of.
According to the case report, the doctor in the operating room is supposed to verify the number of sponges in the pocketed bags.
But in this case, the surgeon did not, and the surgical tech noted that the center divider on the bag could tear and 'the only thing she could think of was, that this happened, and one sponge covered two slots and looked like two sponges instead of one.'
This was not how the bag was meant to be used, and, however it happened, one of the 10 sponges wound up inside the patient, and the autopsy determined that this was the cause of their death.
The California Health and Human Services Agency Department of Public Health is holding the entire surgical term responsible for failing to adhere to the hospital's protocols, and ultimately for causing the patient's death.
This places Mercy in 'immediate jeopardy,' and it make significant corrections to its policies and procedures to ensure something so disastrous doesn't happen again - or risk losing its license.