Saint Agnes Medical Center in Fresno was fined $50,000 by the state after one of its patients underwent a second abdominal surgery—after four painful months—that turned up a misplaced towel.

The California Department of Public Health (CDPH) report upbraided the hospital for not counting the towels after surgery, but keeping track of stuff in surgery is apparently a challenge. Debby Rogers, the department’s deputy director of the Center for Health Care Quality, told the Fresno Bee that leaving foreign bodies inside patients is high on the list of hospital violations.    

Although poorly tracked, often ignored and frequently misdiagnosed, surgical items left behind are believed to be an even more common occurrence than operations on the wrong body parts.

It is common enough to have a name, or two. Gossypiboma and textiloma are both references to complications resulting from leaving foreign materials inside bodies after surgery is complete.

Saint Agnes may have gotten off cheap. Robert Sanner of New Philadelphia, Ohio, collected $275,000 in 2011 when doctors at Louis Stokes VA Medical Center left two towels in his body after surgery to remove a cancerous kidney.

Back in 2001, Sarona Collins picked up $125,000 after doctors at San Francisco General Hospital left a large blue towel in her abdomen. When she returned to the hospital in great pain, doctors removed the towel but accidentally left part of the drain from her colostomy bag in her body.

The year before, Santa Rosa resident Helen Collins received a $40,000 settlement when her grapefruit-size “malignant cancer” turned out to be a big blue towel left over from a 1998 gall bladder operation.

Leaving foreign materials behind after surgery is apparently a common enough problem that there are companies that specialize in products that detect misplaced items. Surgicount Medical touts itself as the “industry leader” in hunting down paraphernalia “to help eliminate one of the most common surgical errors, retained surgical sponges.” It uses bar codes and hand-held body scanners at checkout.

–Ken Broder

To Learn More:

Saint Agnes Fined $50,000; Left Towel in Patient (by Barbara Anderson, Fresno Bee)

Veteran Gets $275,000 after Doctors at Louis Stokes VA Medical Center Leave 2 Towels Inside Him during Surgery (by Mark Gillespie, Cleveland Plain Dealer)

S.F. Settles Suit over a Painful Pair of Surgeries / Towel, Tubing Left inside Woman (by Peter Hartlaub, San Francisco Chronicle)