LEFT BEHIND

At Philadelphia-area hospitals, surgical teams mistakenly left objects inside patients’ bodies more than 200 times over six years. While rare, the error can cause catastrophic harm.

The surgeon at Jefferson Washington Township Hospital promised Todd Gordon that a routine surgical procedure to biopsy tissue inside his chest would be simple and quick.

Within months of the 2020 outpatient procedure, however, the 29-year-old motocross pro from South Jersey found himself laboring to breathe on the short walk to his mailbox. He coughed constantly, and sometimes hacked up bloody phlegm.

Unbeknownst to Gordon, six to eight feet of surgical gauze used to sop up blood during the biopsy had been left inside his chest at the New Jersey hospital. The thin strips of wadded-up gauze became infected, gradually ballooned with fluids to the size of a golf ball, and were squeezing his windpipe shut.

For more than two years, doctors couldn’t figure out what was wrong. He was on the verge of suffocating when a Philadelphia surgeon discovered that Gordon was the victim of an extremely rare but catastrophic medical error: An item used in surgery had unintentionally been left inside his body.

This type of mistake is called a “never event” in medicine, because patient safety experts and government regulators agree that even one instance is too many. Such mistakes are estimated to take place in one out of 5,500 procedures in the United States.

In Philadelphia-area hospitals, surgical teams erroneously have left objects – gauze, sponges, broken drill bits, tips of suture needles, screws, catheter fragments, and guide wires – inside the bodies of more than 200 patients in the six years ending in 2022, an Inquirer analysis has found.

The true toll of these “never events” is unknown locally and across the nation. In Pennsylvania and New Jersey, state safety regulations are supposed to protect patients, but regulatory gaps allow hospitals to avoid scrutiny when they leave surgical items in patients.

To understand the scope of these medical errors and the harm they cause, The Inquirer analyzed Pennsylvania billing records for every patient admitted to a Philadelphia-area hospital from 2017 through 2022, interviewed a half-dozen patient safety experts, and reviewed hundreds of medical malpractice lawsuits filed against area hospitals.

The reporting revealed a chilling array of errors that patients say they suffered:

• An orthopedic surgeon left a “golf-ball-size trial femoral ball” in a 76-year-old Drexel Hill woman’s groin during an August 2021 hip replacement at Delaware County’s Taylor Hospital, part of Crozer Health. Trial balls, typically made of plastic, are temporary implants used to test hip mobility before insertion of a permanent device.

• While operating on a 17-year-old girl’s jaw, a plastic surgeon at Children’s Hospital of Philadelphia in 2016 accidentally broke off a metal bracket from the braces on her teeth. The bracket eventually worked its way inside the soft tissue of her neck, where she suffered a painful infection. CHOP settled a lawsuit with the family in 2020 for an undisclosed amount.

• An obstetrician left a surgical sponge inside a 28-year-old Pottstown woman during a May 2021 emergency C-section at Chester County Hospital, which is owned by Penn Medicine. The sponge caused a “raging infection” that grew into her bowels, her lawsuit says, requiring the removal of parts of her colon and her appendix.

Yet state regulators did not use their power to reprimand the hospitals and order safety fixes in any of these cases.

Since 2017, the Pennsylvania Department of Health has not cited any of the three dozen hospitals where The Inquirer’s analysis found patients underwent treatment for medical errors related to a retained object, a review of public inspection reports found.

State health inspectors also did not come out to look into medical practices when items were left inside patients after surgeries at the hospitals where The Inquirer’s analysis showed these mistakes had happened most often.

Thomas Jefferson University Hospital (TJUH) in Center City and the Children’s Hospital of Philadelphia (CHOP) topped the list, each with seven cases in which a patient needed treatment for a left-behind surgical item that wasn’t there upon admission to the hospital. Lankenau Medical Center in Montgomery County followed with six cases during that same time period.

The three hospitals didn’t dispute The Inquirer’s data analysis, but spokespeople for each said that patient safety is a priority, and that medical providers follow protective measures.

To prevent mistakes, hospitals rely on such safety protocols as requiring nurses to count each item on a surgical tray before, during and after the procedure. Some hospitals also have backup safety measures, such as using X-rays and hand-scanners to check for forgotten surgical items while the patient is still on the operating table.

But those safeguards too often fail.

As Gordon’s health worsened, he said, he told specialist after specialist: “I can’t breathe.” None could explain why the athlete, now 33, was so sick.

He landed in the hospital emergency department twice. He underwent exploratory surgery and had four CT scans, but doctors still could not determine the cause.

In late 2022, a surgeon at Temple University Hospital ordered a major operation to investigate. Joseph Friedberg cut a foot-long incision in Gordon’s back, then he grasped the gelatinous mass with small forceps.

The mystery lump began to unspool into a bloody strip of fabric. Then another. And another. Seven hours later, a bloody trail of gauze, stretching “6 to 8 feet in length,” had been pulled out of Gordon’s body, the surgeon’s report noted.

Meanwhile, Gordon’s wife, Gabrielle, and her mother sat anxiously waiting at Temple. The surgery, which began in the morning, took so long that the waiting room closed for the night. A hospital staffer moved the women to a small, empty room.

“I was beyond worried,” Gabrielle Gordon said.

Finally, at about 11 p.m., Friedberg emerged from the OR and updated them.

“Todd’s OK, but we found something we were not expecting to find,” Gabrielle Gordon recalled Friedberg explaining. He then pulled out his cellphone and showed her a photo of the bloody strips of gauze. He explained that the gauze had caused “a life-threatening airway narrowing.”

“I was speechless,” Gabrielle Gordon recalled. “I took my purse and I chucked it across the room, because I was just so angry, mad, upset, disappointed.”

“All because of a mistake that somebody made,” she said.

Gordon’s medical records show his original surgical team took a standard safety step: an item count to make sure everything used in the biopsy procedure was accounted for. But those records erroneously noted that “all counts at closing were correct,” according to a lawsuit Gordon filed last year against Jefferson Washington Township Hospital in Gloucester County.

Jefferson Health declined to comment on Gordon’s case, citing pending litigation.

A professional motocross racer, Gordon never used to get rattled. He lived off the adrenaline rush of launching his dirt bike over steep jumps, using every muscle in his body to hold on as his heart rate pushed to 175 beats per minute.

He can no longer race. He suffers from panic attacks and depression. The other night, while folding laundry, he inexplicably began to cry. He can’t sleep; instead, he replays the moment he first went under anesthesia, trusting a doctor who had described the procedure as “an everyday thing, easy, in and out.”

“I always viewed it like, ‘If I die on my dirt bike, at least I died doing something I loved,’ or ‘If I get hurt on my dirt bike, that’s on me,’” Gordon said. “These guys almost killed me and I had no control over it.”

A rare but recurring ‘never event’

When medical items get left inside patients, the suffering does not discriminate by age, race or zip code.

The Inquirer’s analysis identified 203 affected patients at 39 hospitals in Philadelphia and its four surrounding Pennsylvania counties. (Comparable New Jersey data were not readily available.)

Patients affected ranged from a 9-month-old girl from West Philadelphia who needed an organ transplant at CHOP to an 84-year-old man from Jenkintown who underwent a heart operation at Jefferson Abington Hospital in Montgomery County.

The state data listed which hospitals, by name and date, reported billing codes associated with the mistake in hospitalized patients.

The data did not specify the procedure during which the object got left or assign blame to a hospital. However, in 65 of the 203 cases, or 32%, the accident occurred during the same hospital stay, meaning it likely happened at that facility.

The 65 cases occurred at Philadelphia institutions such as the Hospital of the University of Pennsylvania (HUP) as well as smaller suburban facilities, such as independent Doylestown Hospital in Bucks County and Main Line Health’s Paoli Hospital in Chester County.

Two of the 65 patients died during their hospital stay, though it’s unclear whether a “never event” caused their deaths.

Mark O’Neill, a spokesperson for Pennsylvania’s health department, said agency staff review all serious events reported by hospitals. The department expects hospitals to examine why an error occurred and take corrective action. State health regulators may work directly with a hospital to ensure fixes, if needed, he said.

Hospitals may not have reported the incidents identified by The Inquirer, he said, which could explain the state’s lack of regulatory action. He also said the state may have determined that the hospital had addressed the safety lapses, or the state investigated and found no deficiencies.

Medical mistakes involving “unintended retained foreign objects” (URFOs) rank among the nation’s top five causes of patient death and severe harm, according to the Joint Commission, the nation’s primary hospital-accrediting organization.

Retained objects also can result in additional operations, infection, permanent organ damage, or loss of bodily function. Each instance costs the health-care system $166,000 to $200,000 in excess medical treatments, according to the federal government.

“This is actually a pretty rare occurrence, so it should not prevent anybody from going to have needed surgery,” said Marcus Schabacker, president and CEO of ECRI, a national nonprofit focused on patient safety in Plymouth Meeting, Pa.

Even so, these errors are unacceptable and alarming, Schabacker said, noting that 75,000 to 100,000 people in the U.S. die each year from preventable medical errors, including surgical objects mistakenly left in a patient’s body.

“I personally can’t accept it,” said Schabacker, an anesthesiologist and intensive care specialist. “I swore an oath to do no harm and we’re doing harm every single day.”

Pennsylvania created the state Patient Safety Authority (PSA), which maintains the country’s largest data bank of adverse patient events. It calls retained surgical items, which “can lead to serious patient harm,” an ongoing challenge.

“Patients may suffer for years with pain and other disabilities as a result,” the authority wrote in a 2017 report that analyzed 128 instances of a retained surgical item over two years at Pennsylvania hospitals.

The most common item left inside patients: sponges used to soak up blood and fluids during surgery.

‘This shouldn’t have happened’

In May 2021, a Pottstown woman named Lauren Marsh, a patient at Chester County Hospital, required surgery that poses a higher than typical risk of a surgical item being left behind.

Long surgeries during which nurses change shifts; complicated procedures with multiple surgical teams; and emergency operations that require doctors and nurses to act quickly are well-documented danger zones.

That’s why hospitals rely on layers of safety to catch forgotten objects.

Marsh was 40 weeks pregnant with her first child and in labor when a nurse at Chester County Hospital pulled an emergency call bell.

The umbilical cord had come out before the baby, a rare complication. If the cord became compressed, her baby would be deprived of oxygen and could suffer permanent brain damage. Doctors needed to deliver the baby immediately by emergency C-section.

As medical staff converged, Marsh remembers that the room became chaotic. “I did not really understand what was going on at the time, other than there were a lot of people,” Marsh said.

Normally, a nurse counts each sponge before the start of a C-section procedure. Then the same nurse counts again before the incision is closed.

But Marsh’s C-section happened quickly, and there was no pre-count of the sponges. Instead, hospital staff relied on a second safety option: an X-ray of her abdomen.

“The C-section was rushed and they wanted to make sure nothing was left behind,” Marsh recalled being told while under local anesthesia and conscious. “That did give me a sense of safety.”

Marsh heard an OR staffer call out: “All clear.”

Notes in her medical chart from the obstetrician who performed her C-section say the X-ray of her abdomen “appears to be without retained instrument, needle, or sponge.”

But the X-ray report, signed by a radiologist just a few minutes later, noted a “5-centimeter” object in her pelvis, according to medical records quoted in a lawsuit Marsh filed last year in Philadelphia’s Court of Common Pleas.

During Marsh’s four-day hospital stay, more warning signs were missed. She repeatedly complained of abdominal pain and had a white blood cell count that signaled possible infection. Staff dismissed her pain as normal, she said.

Over the next several months, the pain worsened. She began to vomit and lose weight. It hurt to bend down to pick up her newborn son. Her stomach was so tender that she had to stop breastfeeding him.

“Basically, I couldn’t ‘mom’ him because of the discomfort, and it impacted my bonding in a major way,” Marsh said.

She went from her family doctor to a gastroenterology specialist and back to her obstetrician-gynecologist.

Finally, about five months after her C-section, her family doctor ordered a CT scan of her abdomen and pelvis.

The scan revealed a dense mass, roughly the size of a large lemon. Sitting just above her uterus, the mass looked to be filled with gas, debris and possible fecal matter. Within the mass, the scan noted what looked like “a surgical sponge,” according to the radiology report detailed in her civil complaint.

A staffer at her family doctor’s office called Marsh and told her to go directly to the closest emergency department.

“That was the first time I knew something had gone wrong with the C-section,” Marsh said. “I was in shock, anxious, confused. I initially pictured a kitchen sponge with the ridges and started to panic.”

The sponge was encased in a large pocket of pus and had invaded her intestines. Doctors thought she was stable enough to wait until after Thanksgiving for the major abdominal surgery she needed.

By the time Marsh underwent surgery at Chester County Hospital to remove the sponge on Dec. 3, 2021, she had “a raging, bad infection,” she recalled.

“They were surprised I was walking and didn’t go into sepsis,” she said, referring to a life-threatening infection.

It took a surgeon roughly five hours to remove the sponge, two damaged sections of her bowel, and her appendix, she said. Fibers from the forgotten sponge had to be removed from her uterus and her right fallopian tube was swollen, according to her lawsuit.

Marsh spent eight days in the hospital.

Her lawyer, Shanin Specter, said the hospital’s error was egregious because the sponge was clearly visible on the X-ray taken just after Marsh’s C-section. He blamed communication failures among her medical providers for the mistake, which left her with permanent damage.

“All completely avoidable,” Specter said.

A Penn Medicine spokesperson declined to comment on the hospital’s behalf, citing the pending lawsuit.

Marsh, now 31, said she wants to have another child but doesn’t know whether she’ll be able to conceive.

“I still have pain, anxiety,” she said. “This shouldn’t have happened.”

A glaring gap in patient safety law

Pennsylvania and New Jersey have laws that require hospitals to report serious medical errors to state regulators.

But there is no evidence that motocross racer Todd Gordon’s case was reported to New Jersey health regulators.

Since 2002, Pennsylvania has required hospitals to report serious events, meaning medical errors that cause death or unanticipated injuries that require additional treatment.

The law relies on hospitals to self-report their errors. But hospitals do not have to report serious events they learn of that were caused by another hospital.

That means Pennsylvania hospitals that uncover an object mistakenly left by a surgical team at a different hospital are not required to notify anyone. That includes the state health department or the state’s Patient Safety Reporting System (PA-PSRS).

Hospitals also are not required to inform the offending hospital. Rather, the law says such a notification is “strongly encouraged.”

In Gordon’s case, news that long strips of gauze were pulled out of his body circulated among Temple University Hospital staff. “While in the ICU, I had people coming from all over the hospital, saying ‘I heard what happened,’” Gordon recalled.

The hospital’s new chief medical officer, Carl Sirio, told The Inquirer that he had heard about Gordon’s case shortly after he joined Temple’s staff in January 2023.

But Temple declined to tell The Inquirer whether it alerted Jefferson Washington Township Hospital about the gauze that was left behind in one of its surgical suites.

From now on, Temple will report errors it discovers to the original hospital, Sirio said.

“It’s not standard practice, but as a moral obligation to make the system better, we owe that courtesy call,” said Sirio, an internist and critical care doctor.

New Jersey law requires hospitals to investigate their own serious errors and make recommendations to avoid repeat cases.

Even so, there’s been no indication that the Jefferson hospital reported the error that harmed Gordon to New Jersey’s state health department, or investigated itself, according to his lawyer, Virginia Lowe, who sued the hospital last year in New Jersey Superior Court in Camden County.

Jefferson Health, which is headquartered in Philadelphia and owns Jefferson Washington Township Hospital, declined to say when the hospital first learned about Gordon’s case and whether it alerted New Jersey health officials.

A spokesperson for the New Jersey health department said she could not comment on whether the hospital notified the state because reports are confidential under the law.

“There’s a lost opportunity to improve patient safety here,” said Lowe, who became a lawyer after decades of practicing medicine.

“If neither the state nor the hospital where this occurred are notified, there is no opportunity for the hospital to investigate how the mistake happened and no opportunity for them to take steps to make sure it does not happen again.”

An unceasing nightmare

Nearly four years later, Gordon wishes he never had the biopsy that left the gauze in his chest.

Doctors recommended it only after seeing a troublesome spot on a CT scan when he crashed his Kawasaki KX450 bike and landed in the ER. At the time, he was training for motocross nationals at a track in Egg Harbor Township.

The biopsy ruled out cancer but found a highly treatable inflammatory disease that can cause some breathing difficulties. But Gordon never had symptoms, and before the biopsy, he lifted weights and jogged several times a week.

In the weeks after the biopsy, Gordon repeatedly complained to doctors that he felt as if he were trying to “breathe through a straw.” Doctors put him on antibiotics, steroids, asthma inhalers, and immunosuppressive medication, mistakenly believing his symptoms could be related to the inflammatory disease. Nothing helped.

At one point, he went to an allergist because he thought maybe he was allergic to the stray cat he took in.

Today, he’s still trying to recover from the botched biopsy. About two months ago, Gordon had an operation to repair a hernia, caused by nonstop coughing from the gauze. The hernia repair was his third surgery related to the “never event.”

The hernia surgery left Gordon too weak to return to his job as a terminal operator at an oil storage facility on the Delaware River. The work requires him to climb oil tanks and check gauges.

So far, the costs for his medical care due to the left-behind gauze have totaled about $250,000, according to an estimate from his lawyer. That figure includes an eight-day hospital stay, with four days in the ICU, after the surgery at Temple to remove the gauze. Gordon’s private health insurance covered most of it.

Gordon said he misses motocross, snowboarding, mountain biking – all the things that made his life adventurous.

“I’m still trying to wake up from this nightmare,” he said.