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To err in surgery?


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In an effort to become a bit more worldly, if you will, about my nursing practice (ok, and in avoiding studying for the night), I stumbled upon this article about a surgeon who caught his own mistake. In the hustle and bustle of his day, this doc got lost in thought, performed his pre-op patient interviews out of order, and ended up performing the wrong procedure entirely. A patient who needed a “trigger release” procedure (cutting the tendon in a finger) ended up with a “carpal tunnel release” (removal of a band of tissue around the wrist).

As the article states, mistakes like this one have contributed to the “44,000-98,000 Americans who die each year in US hospitals from preventable medical errors.” In 2004, The Joint Commission came up with the “Universal Protocol” to prevent these errors from occurring, which includes the “Time Out” process that we’ve all seen and heard and participated in before a procedure or operation.

To err is human. We’ve all heard that one before. And while I credit this surgeon for catching his mistake as he went to record his notes, and publicly apologizing, I feel like it’s seriously ridiculous that there are THAT many medical errors in the US. I mean, really.  With al the technology and knowledge that we have, is it really THAT hard to check you “rights” (right patient, right procedure, right extremity, etc)? I get that we’re human, and mistakes happen, but this many, especially in the age of the Universal Protocol.

And on that note, I’ve seen the universal protocol performed before surgeries before, but hadn’t ever really learned much else about it. So after reading about it, I searched it on a nursing message board and was surprised by the number of angry nurses commenting about it shortly after it had been mandated by TJC. Complaints like, “as if getting the H&P from the doc wasn’t hard enough, now we have to wait for him to ‘time out’?” really scare me. First of all, I always try to think of the situation as if I were the patient lying on the table, and if that were me, I don’t care if you have to yell at the doctor to do it, but you BETTER be making sure you’ve got all your facts straight before you cut me open. Secondly, the ‘time out’ is not much different from other protocols that are innate in our nursing practice – checking ID bands and the 5 rights of med administration.  When there is so much resistance to performing another patient check such as the universal protocol, especially in such an imperative situation as surgery, I feel like these extremely resistant nurses are probably skipping steps in med administration and other procedures in their nursing care as well. I get that change is tough sometimes, but we have to put patient safety first.

So what does this mean to us as students? For one, practice your patient ID band checks, make sure you check your meds three times, practice your 5 rights. Even when you’re just observing, check your patient. Take the few seconds you need to explain something to your patient before you do it. It also says to me that we need to be cognizant about what is going on in the hospital. Even though we may be at the bottom of the totem pole in the clinical setting, doesn’t mean we can’t make sure it’s the right patient, right procedure, or that we can’t say, “hey, is this they right guy?” This is a profession of integrity, and as nurses, we’re the one’s advocating for the patient, and if nothing else, we must advocate for their safety.

Ani Burr, RN
I'm a brand new, full-fledged, fresh-out-of-school RN! And better yet, I landed the job of my dreams working with children. I love what I do, and while everyday on the job is a new (and sometimes scary) experience, I'm taking it all in - absorbing everything I can about this amazing profession we all fell in love with.

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