The Folly of Ordering, Then Ignoring, Radiographs

This case involves a very common issue–a clinician orders a test and then does not look at the results or looks at them much later, depriving the patient of a complete diagnosis. This particular case involved a surgery, but whether you are a surgeon or a general practitioner, tests that are ordered should always be followed up on.

Clinical Scenario

The patient was a 58-year-old woman with severe colon inertia which medication had not improved. Her first surgery was an exploratory laparoscopy. The patient had extensive scarring and adhesions, as well as a dead spot in the colon. The physician removed part of the colon and attached the small intestine to the sigmoid colon. After this surgery, the patient developed an anastomotic leak, resulting in bowel contents leaking into her abdomen. This resulted in another surgery the next month. Each time the physician would attempt to fix holes in the bowel, it would break down after surgery and leak bowel contents into the abdomen. Eventually, the physician decided to let the patient heal from the infection caused by the leakage for 3 months, after which he would try to hook up the colon and intestines.

Three months later, the patient underwent a 17-hour laparotomy. As the surgeon was getting ready to close the incision, the scrub nurses told him that the sponge count was off and that one was missing. The physician ordered a radiograph, but before he looked at the results, he found what he believed to be the sponge, removed it, and was told by the medical team that the sponge count was now correct. However, it was not. The radiograph, which had not been looked at, actually showed that 2 sponges were in the patient, and the physician only removed one of them.

Over the next 2 months, the patient had further surgeries to correct a fistula which kept opening.  Eventually, the physician looked at the radiograph from the 17-hour surgery and realized that a sponge still remained in the patient. The physician told the patient and her husband about the sponge but indicated to them that it wasn’t causing any problems at this time.

A few months later, the patient developed an infection that the physician suspected was caused by the sponge. Two unsuccessful surgeries were conducted to attempt to remove the sponge, but the patient’s spleen was injured during one of the surgeries and the sponge was not removed.

The patient was transferred to another hospital, where she had numerous surgeries over the next year to address holes in her intestines, infections in her abdomen, fistulas, abscesses, and finally a bowel transplant. A week after the bowel transplant, the patient began bleeding severely and was taken to emergency surgery. At that time, the transplanted bowel was removed so that doctors could stop the bleeding. By the time the bleeding was stopped, the physicians concluded that the grafted intestine was not healthy enough to put back in the patient. The patient remained in intensive care following the surgery and died several weeks later due to multiple organ failure.

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