When a bulb does not represent a good idea

#TPSER8 We are all familiar with the cartoon image of a light bulb glowing or flashing as representing a good idea that has occurred to someone.  There are other types of bulbs, including those used in medicine, which are also good ideas, except when they are left in the wrong place.

A case documented in the Journal of Robotic Surgery (2009) 3:45-47, entitled, "To forget is human: the case of the retained bulb," presents a whole new category of retained foreign objects in people who have undergone laparoscopic surgery.  In this case, a 34-year-old woman had a robot-assisted laparoscopic hysterectomy.  An asepto bulb was placed in the vagina by the surgery technician "to maintain the pneumoperitoneum during the laparoscopic closure of the vaginal cuff."

Wikipedia tells us that, "A pneumoperitoneum is deliberately created by the surgical team in order to perform laparoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide."

Here's how the bulb is usually configured, as part of an irrigation syringe.  In this case, the bulb was removed from the syringe to be used by the surgery technician.  In essence, s/he used it to plug up the pressurized air pocket in the abdomen needed by the surgeon using the laparoscopic instruments.

You can almost imagine the surgeon saying -- sitting in his robotic console physically apart from the operating table -- "I am losing air pressure.  Do something to stop the leakage."

Here's the interesting aspect of the case.  Unlike sponges and other operative supplies, "No verbal or written account was made of this action."  And then the non-hand-off occurred, "Subsequently, the scrub technician left the room prior to the end of the case in order to help with the next case."

"The procedure was uneventful and the patient was discharged the same day."  Except for one thing.  The bulb was left behind.  A few days later, the woman and husband came back, the object was found and removed, and after some ensuing complications, she was fine.

I first learned of this case from my colleague David Mayer here at Telluride.  He related other similar cases that he has heard about.  We discussed how a new set of operative procedures can create its own cottage industry of opportunities for patient harm.  How?  Well, it all goes back to the fact that clinicians and their assistants are extremely task-oriented as they take care of patients.  Here, the surgeon expressed concern about an inability to proceed with a case because of gas leakage.  The surgery technician, responding in the moment, cleverly created a solution that enabled the surgery to proceed.  S/he was then distracted by the next task and forgot that the solution had left behind a foreign object -- or maybe s/he figured the "next person" would remove the bulb.  The surgeon might not even know how the leakage was stopped.  Even if s/he knew, s/he would certainly not stop to ask if the the bulb had been counted, perhaps assuming that it would be counted in the same manner as sponges.  The absence of a standardized work protocol for this type of procedure and its contingencies was the systemic cause of harm to this patient -- and patients in other hospitals.

Further, if David is correct that this error has occurred elsewhere, we can note that there is no reflection of those cases in the literature.  Doctors and hospitals are very reluctant to publish papers indicating errors that they have made or that have occurred in their hospitals.  The inability of the profession to take note of this category of error is therefore inhibited, further increasing the likelihood that it will take place again.