A Personal Story:

Why I Have Created This Site:

Let me first tell you a personal story from many years ago. This "story" imprinted on my heart the damage that could occur to a patient and to their family! What occurs to one family member affects the entire family. This "story" molded my nursing practice early in my career and focused my attention on patient safety in the operating room up to the day I had to retire from nursing because of my own post-op health issues.

Because of my passion for patient safety, I can say thankfully that I never had a patient incident in over 33 years. I did inherit a few "bad" cases on which I relieved but all my cases had good outcomes. I give God the glory for my patients' good outcomes.

From my perspective, as I recall, my "story" goes like this: I relieved another RN in an operating room so that the RN could go home. Our job description is called the OR Registered Nurse Circulator. There is supposed to be a RN who is in charge of each OR and each patient, during the entire time of the procedure. He / she collaborates and coordinates with the rest of the team to make sure EVERYTHING is ready to go for each surgical case. It is all about safety! It is very comforting to have your hand held by the RN or by someone else as you fall asleep or while you get your block put in, BUT let me tell you, once a patient is asleep or is heavily sedated, the nurse's duty IS ALL ABOUT SAFETY!

One medication used to decrease a patient's anxiety pre-op is VERSED, however, VERSED also produces amnesia. I am sure that some patients don't even remember me interviewing them as I did my pre-op evaluation before they came into my OR room! Who knows when a patient is given the feel good medication!

After relieving the RN, the case finished up a few minutes later. The female patient was overweight per standards today. She underwent a long procedure with her legs in "candy cane" stirrups. Upon two of us removing her legs out of the stirrups, it was noted that there was a prominent white mark on both side of her groin. I checked for pedal and femoral pulses but they were not present. With my heart in my throat, I turned to the surgeon and told him my findings. I really didn?t comprehend at that point what had happened but that poor woman had to have both of her legs amputated that week! There was no blood circulating in her legs! She had a BK (below the knee) and an AK (above the knee) amputation! The findings were shared that the woman's heavy legs, while up in the stirrups, compressed against her belly and then compressed her femoral arteries shut, that is the main arteries in the legs were occluded! I became nauseous. I wanted to throw up!

An RCA (Root Cause Analysis) was performed, which is done after the fact might state:

1. The obesity factor should have dictated that the patient should have had her procedure in a supine position (lying flat on the table) instead of her being placed in a lithotomy position (in stirrups)

2. Different stirrups should have been used which would have protected the patient's legs from any undue or unusual pressure.

3. Time is a factor in any surgery but since time was a factor in this case, the patient's legs should have been checked for "proper positioning and circulatory issues" and any staff could have put their hand into the femoral, i.e. groin, area to make sure there were strong pulses.

The RCA list can go on and on BUT my point is that the entire surgical team is responsible for sharing information, and brainstorming all possible scenarios which could occur. For example, IF one OR team member was told, "by the way, our patient has a family history of Malignant Hyperthermia" and that this info did not appear on the chart, nor was it shared with anyone else, this critical information would be shared with the team and especially the OR/RN Circulator who would make sure that Dantrolene was in the OR room ready to be mixed (in case it was needed).

The moral of this small example is that the more staff asking the patient's pre-op questions the better it is for the patient! As an RN, I always had a huge "mental" list of questions, which I reviewed with the patient after I read the patient's chart. I have seen some ridiculously scanty / incomplete pre-op questionnaires over the years. To add to this dangerous lack of information is the patient's anxiety and forgetfulness and even the lack of being able to communicate if intubated or heavily sedated or comatose.

So, as an RN, more is better for the patient. If a patient complains about the redundant questions, just reassure them IT is for their own safety! There are no Lone Rangers in the OR, so, to all patients everywhere, the sharing of information is good for you and for the staff. However, it is you, the patient, who will benefit the most! In conclusion, and in preparation of many more "OPERATING ROOM RN WATCHING OVER YOU" discussions to come, I would like to make a call for action to prevent the "never events." A never event is popularly defined as "serious and costly errors in the provision of health care services that should never happen," and include issues such as:

• Surgery performed on the wrong body part

• Infant discharged to the wrong person

• Patient death or serious disability associated with a medication error

• Foreign objects left in patients after surgery

A real call for action is needed, not hampered by politics nor hidden by a cover of mistruths and arguments. A call for erasing the mentality of the Emperor's New Clothes so that a mother, whose child has died in a surgical suite, doesn't have to go to the trouble of being part of some foundation in memory of their child's death. What mother or father or family member or friend would not rather have their loved ones alive and unhurt? Memories like graduation, marriage, vacations, snuffed out because they will never be! Let us all be honest and work together to PREVENT all "Never Events." I believe the list is now up to 42 never events. Read it for yourself on the Internet.