Archive Staff & Patient Safety 2018

Left-Behind Needle Proves Fatal

Lessons learned from the tragedy a final count might have prevented.

Jared Bilski


Pamela Bevelhymer, RN, BSN, CNOR
SAME PAGE Surgical teams must work together and use a standardized approach to account for every item used during surgery.

Last May, John Johnson underwent open heart surgery at TriStar Centennial Hospital in Nashville, Tenn. At the end of the 9-hour procedure, the surgeon closed Mr. Johnson’s chest and rewired his sternum. The procedure appeared to be a success.

Wait, are we missing a needle?

The surgical team ordered an X-ray, which confirmed their worst fear. The surgeon put Mr. Johnson, 73, back on bypass and re-opened his chest to search for the needle, allegedly without obtaining a CT scan to pinpoint its exact location, assessing the risk versus the benefit of surgical intervention or even contacting the family about the plan, court records show.

After 3 hours of searching, Sreekumar Subramanian, MD, sewed Mr. Johnson back up and sent him out of the OR with the needle still in his chest.

For the next month, Mr. Johnson experienced multiple system failures until, on June 1, he died a “painful, unnecessary and wrongful death,” according to a lawsuit filed by his family, who’s suing TriStar Centennial for negligence and is seeking $5 million in damages. The lawsuit alleges Dr. Subramanian and the surgical team did not perform a final needle count before closing Mr. Johnson’s chest.

“We take the responsibility of properly caring for our patients very seriously and empathize with the understandable grief being felt by the family,” says the hospital in a prepared statement. “We would like the opportunity to review the specifics of the claims being made and then determine how best to respond.”

Why do these never events keep happening and what can you do to ensure nothing is left in a patient on your watch?

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