Good Doctors Spot Mistakes, Save Lives

Where the devil is that thing?" I hear myself saying. It is almost noon, and I'm finishing a surgical procedure to remove a cancer of the esophagus from a 54-year-old man. I've already brought his stomach up into his chest to replace the esophagus. He should be able to eat normally within a week. Only our "sponge count" is incorrect, and I can't close the chest until we find the six-by-six-inch piece of cloth we call a "lap pad."

The nurses have turned the operating room upside down. They've emptied all the "biological" waste baskets, searched the floor, rustled all the sterile drapes and recounted the used lap pads.

Additional help has been summoned to the room while I am looking in the chest for the missing pad and seeing only the patient's steadily beating heart.

Everybody in the room knows that prolonging the operation has a deleterious effect on the man who has entrusted us with his care.

Body fluids evaporate from open cavities, and the patient's core temperature falls because of evaporation and the cool room temperature. Yet we can't close until we find the damn thing.

How can anybody lose a sponge the size of a dinner napkin inside a human being? It is easier than you might think. In fact, medical harm is more common than those of us who celebrate the "most advanced health-care system in the world" would like to admit.