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Patient Falls Off OR Table: System Error?

An anesthetized patient fell to the floor headfirst from an operating room (OR) table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head-down position to facilitate the operation. Fortunately, no injury occurred. The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient. The hospital has experienced 11 other major surgical errors in the last year, including two instances of wrong-site surgery and a case in which five swabs were left inside a single patient. An investigation by the hospital noted that the level of situational awareness of staff in the operating theatre was inadequate, and teamwork and communication were poor. In addition, the safety culture within the OR was described as not highly attuned to patient safety. The staff was also distracted by mobile phone use and idle chatter. Instead of addressing the obvious human errors such as failure to place the safety strap, which in US hospitals is clearly the duty of the circulating nurse, the hospital’s plan of correction focused on the following typical system-type corrections: Compulsory training of 1200 staff. Although there were 10 staff for a laparoscopic appendectomy (in the US there would be 4: nurse, scrub tech, surgeon, anesthesiologist), I doubt that there are 1200 people working in the OR of this 570-bed hospital. What will those not working in the OR have to gain from compulsory training? I wonder if anyone considered that 10 staff for an appendectomy is far too many, and that’s why there...

The “Second Victims” in Nursing

Tears rolled down my face as I came across an article written 2 years ago. A veteran pediatric nurse took her own life several months after administering a fatal overdose of an electrolyte to an infant. After investigations and undisclosed reasons, the hospital terminated the nurse’s employment after 27 years of service and dedication to the profession she truly loved. To further satisfy the state licensing disciplinary actions, she agreed to pay a fine and  undergo a 4-year probationary period. She would be supervised at any future nursing job when she gave medication. She even successfully completed a course to qualify as a flight nurse. Yet countless efforts did not produce any job offers, increasing her despair and isolation. A friend said, “She cried for weeks. Not just because she lost her job; she lost a child.” No one knows all the details that led to the nurse taking her own life. The reality is, the healthcare industry, I believe, is not set up to provide personal, psychological, and social  support to the “second victim” of medication errors. The first victims are the patients who were harmed and their families. Nurses are the providers of care and support for  patients. But who supports and advocates for nurses? Nursing, as noble as this profession may be, can also be a lion’s den. When mistakes happen, we are urged to “write it up,” appear in front of a committee, get judged, and God only knows what else. Then, labeled as “incompetent,”  an unseen force can immediately make the second victim even terrified to go back to work, adding to the feeling...

Surgical Catastrophes and Anesthesiology

Most anesthesiologists will experience at least one perioperative catastrophe over the course of their careers. These events may have a profound and lasting emotional impact on anesthesiologists and may affect their ability to provide patient care in the aftermath of the incident (see article from guest blogger, Skeptical Scalpel, Complications & Collateral Damage). In an effort to more closely examine the impact of perioperative catastrophes on anesthesiologists, my colleagues and I conducted a survey that was published in Anesthesia & Analgesia. We sent a questionnaire to 1,200 randomly selected members of the American Society of Anesthesiologists who were practicing in the United States. Among the 659 anesthesiologists who completed the survey, 84% had been involved in at least one unanticipated death or serious injury of a perioperative patient during their career. Catastrophic Events Have a Lasting Impact When we asked anesthesiologists to recall their most memorable catastrophic event, more than 70% reported that they experienced guilt and anxiety and reliving the event. Most felt personally responsible for the death or injury, even if they considered the event to be unpreventable. The vast majority (88%) required time to recover emotionally from the catastrophe, and 19% acknowledged having never fully recovered. Another 12% even considered changing careers in the aftermath of the catastrophe. In addition, about two-thirds of the anesthesiologists reported feeling that their ability to care for patients was compromised in the first 4 hours after the event. However, nearly all respondents reported that they carried on with their usual work schedule after the incident occurred. In fact, only 7% were given time off. Our results clearly demonstrate that surgical...
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