COMMENTARY

Did a Missing Sponge Cause This Patient's Death?; More

Wayne J. Guglielmo, MA

Disclosures

August 21, 2014

In This Article

Did a Missing Sponge Cause This Patient's Death?

Along with towels, surgical sponges are left behind in patients more often than any other item. Surgeons use an average of 20 sponges per procedure, so their sheer number makes them difficult to track. Adding to the problem is that during surgical procedures, sponges absorb blood, causing them to blend into the background such that they seem to disappear.

A recent medical malpractice trial in Ohio concerned a surgical team's laparotomy sponge that was left behind during an operation on then 57-year-old Eugenia A. Snowden, who died 15 months later. The defense team didn't argue this; however, they did deny that the mistake led to her death, as reported in a story in the Dayton Daily News.[1]

In late February 2009, Snowden underwent a 17-hour surgery at Miami Valley Hospital, in Dayton. Told by surgical team members that the sponge count was off, the head surgeon -- Akpofure Peter Ekeh, a member of Wright State Physicians -- ordered an x-ray. Before examining it, though, Ekeh removed what he believed was the missing sponge from the patient's abdomen and was told by team members that the count was now correct.

It wasn't. There was a second sponge in the upper-left quadrant of the patient's abdomen, which the x-ray showed. However, Ekeh didn't actually look at the x-ray until "five or six weeks later," according to the plaintiff's attorney.

He operated twice to remove the sponge but was unsuccessful, electing after the second failed attempt to refer his patient to the Cleveland Clinic, where after a nine-hour operation on October 1, 2009, surgeons finally removed the foreign object.

Ekeh's attorney acknowledged to jury members that his client had deviated from the standard of care by not immediately examining the x-ray he himself had ordered. But it was the patient's "complicated intestinal history" and not the sponge left behind, he argued, that caused her death. The trial's outcome hasn't been reported yet.

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