Hospital launching investigation about surgical equipment in patient

Hospital launching investigation about surgical equipment in patient »Play Video
A CT scan shows an object inside Heidi Carlson's pelvis.

PORTLAND, Ore. – Officials at Legacy Health say they are conducting an internal review after a patient said a piece from some robotic surgical equipment broke off inside of her.

KATU first reported on Heidi Carlson’s story on Monday night. She said during hysterectomy surgery at Legacy Emanuel Medical Center in September a piece from a da Vinci Surgical System broke off inside her pelvis.

She had complained for months of pain, but doctors didn’t find the source until a CT scan showed the object inside of her.

We tried to speak with a representative from Legacy on Tuesday, but spokeswoman Amber Shoebridge said the hospital declined any interviews and would only provide a short statement.

“Ms. Carlson was a surgical patient at Legacy Emanuel Medical Center. We take our patients’ safety very seriously and are conducting an internal investigation,” the statement said.

What can patients do?

If you are facing surgery it can be difficult to find reliable information to see how hospitals stack up when it comes to medical mistakes.

The health care industry mostly polices itself; however, there is a lot of incentive to do things right. Not only is it ethical, but a series of problems can drive up malpractice insurances costs.

To see how hit-or-miss hospital data can be, take a look at the new website, which compiles hospital safety reports. It lists 34 medical mistakes or deficiencies at Portland hospitals in the last 2.5 years.

We know, however, that those records are incomplete. That’s because we can look at data from the Oregon Patient Safety Commission.

Each hospital is given a goal for a number of incidents to report each year based on the number of procedures the hospital performs.

Last year none of the major hospitals in the metro area hit the reporting goal, though we're told they came close. Here are the goals for 2012:

  • OHSU – 29
  • Providence Portland – 20
  • Providence St. Vincent – 25
  • Legacy Emanuel – 16

Oregon hospitals are supposed to voluntarily report medical mistakes to the state agency.

The specific details of what went wrong are not a public record.

“I’m frustrated by the amount of time it’s taking to see a lot more reporting,” Bethany Walmsley with the Oregon Patient Safety Commission told KATU in April. “We are making progress across the board but I wish I could go faster.”

Also in April, the chief medical officers at OHSU told us that medical mistake reporting is flawed. He said different hospitals choose to report different kinds of mistakes.

“I think the reason you’ve seen health systems in the metro area not submit the total number of reports is they haven’t seen the value in the data or the database that’s being built,” Dr. Chuck Kilo said.

By comparison, the State of Washington does a better job of breaking down mishaps by each hospital. They list those events on the state's website.

Da Vinci Surgical System

There are several pending lawsuits around the country against the company that makes the da Vinci Surgical System, which Carlson said was used in her surgery.

Most have to do with patients who said they were burned when microscopic cracks developed in the protective covers of the surgical tools.

Those covers are supposed to prevent electricity from shocking the patient.

Last year the company issued a recall for the tip covers on the scissors implement of the robot.