O C T O B E R 2 0 1 8 • O U T PA T I E N T S U R G E R Y. N E T • 5 9
L
ast May, John
Johnson under-
went 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 ster-
num. 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 nee-
dle, allegedly without obtaining a CT scan to pinpoint its exact loca-
tion, 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 fail-
Jared Bilski | Senior Associate Editor
Left-Behind Needle Proves Fatal
Lessons learned from the tragedy a final count might have prevented.
• SAME PAGE Surgical teams must work together and use a standardized approach to account for
every item used during surgery.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
