March 12th, 2012
By Jennifer Olin, BSN, RN
In healthcare, we are loath to admit it, but mistakes do happen. Unlike many other jobs, when our mistakes happen someone may be injured or even die. This is terrifying and as nurses we should always be aware of the possibility.
This weekend, on CBS Sunday Morning, Dr. Sanjay Gupta, neurosurgeon and CNN medical correspondent, made a guest appearance promoting a book he has written. Its premise: medical mistakes. Now, his characters are fictional and so are their situations, but the premise of mistakes and Monday morning quarterbacking are very real.
If you are lucky, really lucky, you will never make a mistake when caring for a patient. If you are a little lucky, you will make a mistake and it will have no serious consequences. I can tell you from experience, even with no real consequences, making a mistake with a patient is gut wrenching.
It Can Happen To Anyone
Many years ago I was involved in a wrong site surgery. I didn’t find out until well after the fact and the patient was fine, all along.
In the briefest of descriptions, my patient had matching wounds, one on each leg, in approximately the same place. He was admitted to my hospital to have both wounds repaired in separate surgeries, the left on one day, the right a few days later. He was consented for the first procedure. I checked which leg we were operating on that day. The consent was correct, the correct leg was marked, and the patient confirmed verbally which leg we were taking care of that day and off to the OR we went.
The patient was prepped and draped, the procedure completed and he left my care for the PACU (post anesthesia care unit). A few days later he came back for his other surgery and there was some confusion. The consent read the same as the previous one. After all our checks we had operated on the wrong leg.
You may be saying, “so what, he had identical wounds and was expecting surgery on both.” Admittedly, no harm was caused, the physician had talked to the patient and we proceeded with his plan of care.
I was sick to my stomach. I get that awful feeling today, 10 years later, as I write about it. There is a “what if” in my mind every time the case comes to mind. We were lucky! It doesn’t matter that there were no harmful consequences to our actions; we made a mistake. In my specialty area, on another day, another patient, it could have been an amputation. Then what?
I can tell you, to this day, I take laterality (the side of the body in which the symptoms of disease are manifested) extremely seriously. I check, double check and triple check with every one of my patients that we, as the surgical team, are on the correct side. That was my lesson learned.
How Do We Fix It?
Gupta says, “How do we as a profession avoid repeating in the future what we have done in the past?” This is an excellent question. One, almost every caregiver has confronted at some time.
Systems and standards are our first line of defense against making mistakes again. We check, double check, and triple check what we do. There are national systems that are put into play, like The Joint Commissions development of the mandatory Universal Protocol, more commonly known as “Time Out,” for surgery. There are facility wide systems for procedures like blood transfusions. There are the standards of practice we are taught in nursing school, like the five, six, or eight “Rights” of medicine administration. We will look at each of these procedures in more depth throughout this week.
Finally, there are the very personal checks and balances everyone who has ever made a mistake puts into play. For me, when I interview a patient just before surgery, I ask the same questions in exactly the same order, every time. That way, I don’t miss one. It’s my personal system.
Paperwork, protocols, checklists, and the like are way of life in healthcare. As cumbersome and tedious as they may seem on a daily basis, they serve a purpose. To give us systems and standards to keep mistakes at bay.
Gupta quotes statistics, saying roughly 100,000 deaths each year in the United States are caused by medical errors. According to the Institute for Healthcare Improvement, medical harm occurs 15 million times a year. Their numbers say 200,000 patients die each year due to avoidable mistakes and hospital acquired infections. These numbers aren’t new but they aren’t changing either. These numbers were released in 2008, 2009 and 2010. And, according to the experts, these numbers continue to grow at about one percent a year despite all the safeguards we put in place.
All these facts and figures, systems and standards shouldn’t make us re-think our career choices. What they should do is make us think. Even as we are pushed to see more patients, provide more care as less cost and deal with a population that is living longer with more serious illnesses we can know we are doing our best—if we stop and think. To paraphrase, we are only doomed to repeat our past if we don’t learn from it.