Medical Mistakes

Dear Operating Room Patients.

I missed writing my weekly discussion last week because I was having so much pain that I could not sit still long enough to write anything. My terrible pain stems from post-op issues from an anterior neck discectomy last year.  I had neck surgery and ended up with arm pain as well as an implant protruding into my esophagus, and that is just part of the story! So, it is not very enjoyable eating nowadays, in fact I have to think about eating now! Chewing small bites slowly, and keeping my mouth moist with lots of water helps but the scary thing to me is that, although I have a mental list of foods that do cause me to gag or choke, I never know "what" other items will gag me or cause me to begin choking until I "almost" cough up my guts trying to get the "item" up. It was interesting to view a recent "Barium Swallow Test" of my throat which showed very clearly, the "indentation", caused by the neck implant, in my esophagus, i.e. it narrows the lumen of the esophagus right under the epiglottis!

So here I am today, not just writing my discussion to educate operating room patients but to let you know about my issues also! I always wanted to start up a website regarding "patient safety in the OR" but since I had to quit nursing after my operation and I hung in there as long as I could, my "retirement" came too early. Not only has my quality of life decreased tremendously but I also had a sudden loss of salary. Now I am petrified to have the "additional" surgeries I need to "repair" my neck surgery.

I have mentioned in an earlier discussion, to you dear patients, that I have been web searching for many years about the issue of operating room errors. I have lived the operating room scene for over 33 years and although there are patient successes, believe me, no one, except the operating room managers, know what is going on in the ORs throughout the USA. In my opinion, there is so much under-reporting and looking the other way, that the same mistakes and new mistakes are never reported. If you don't believe me do some research on your own! The numbers being reported are the tip of the iceberg, and are coming from valid organizations and institutions as well as from valid personal stories from patients or from their friends and families!  I think the operating room truly "buries" its mistakes.

One article by a nurse stated that healthcare professionals need to learn to say, "We're very sorry".  The physician who operated on me did not say "I'm sorry," but rather he told me "I make mistakes." However, just as I was told by one of my old Catholic priests in Sunday school many years ago, "If one is not sorry for their sins, then one is not forgiven for those sins, no matter how many times one might go to confession!" So while healthcare professionals need to say, "We're very sorry" for "unanticipated outcomes" it will not make up for anyone's "unanticipated outcomes".

In another article, a nurse was quoted as saying, after making a medication mistake, "The good news? You do eventually get over it."  I'll bet, in fact I know, it takes a little longer time for those who have been injured to "get over it,” not to mention the suffering, and expenses. And IF a death of a loved one occurred then that incident "injures" and affects many others, mentally, spiritually, and financially!

The culture today seems to not want anyone to be blamed. "We had to abandon blame as a major mode of action," states another nurse! BUT, I'll stand by my view till I die that 95% of all "issues" in the operating room would not occur IF the operating room "nurse" managers ran a tight ship. Oh yes, there is a lack of education in even the basics of operating room guidelines, sterility issues, anatomy, etc as well as the issues of "unnecessary" speed during a case and between cases, and especially arrogance.  Arrogance in that some staff do not know their real or legal "limitations" or let alone the issue of "nursing delegation" (if there is a nurse present to delegate) and the arrogance of some surgeons.  I can recall one arrogant physician who stated to me when I added some FYIs to his comments to a student about "How to catheterize" a male patient, the surgeon said to me, "Do you want me to go to the bathroom and take a piss, while you teach her how to put in a catheter?!" I told him, "Sure, go ahead" and I continued to teach! The way I see life is that it is all about teamwork and learning from each other. And in the operating room, our most important “product" is our patient and their safety!

When I was in the hospital, and needed assistance to go to the bathroom, since I was too weak to go on my own and since the bed rails were all up, I tried and tried and finally found my call light. Sure, someone answered it but no one came! Several times after that, in a Magnet hospital, there I was peeing in my bed, how embarrassing. I felt too badly to say anything until later after returning home.  Even some of my trays of food, and I did not eat for several days, near the end of my stay, were brought in and removed without giving me a chance to try to eat. I could not get out of bed and get the trays of food which were placed on a counter across the room. So the moral of this is that no matter how many expensive "bells and whistles" a hospital might have, they do not help the patient if the "bells and whistles" are not answered or interpreted properly! I could have become a CMS (Medicare / Medicaid ) "never event" i.e. I could have had fallen out of my bed and broken my hip when I attempted to get out of bed trying to get to the bathroom. Thank God, I guess, that my bed rails were up but that is another "issue.”

I will be giving you all many examples of sentinel issues in my future discussions. I don't want to scare anyone BUT "forewarned is forearmed"! I pray that some of the "issues" which I will post, will be relevant to many! PLEASE ASK, ASK, ASK and take notes of everything as well as staff names when you or a loved one is in the hospital! And never leave anyone in the hospital without someone being there 24 hours around the clock.  One might not be knowledgeable about healthcare BUT believe me, YOU will pick up problems! YOU can be the "patient's voice". Also, ASK about the medications the patient is receiving and ask about the dose.  You might not know anything about the drugs or doses BUT you will draw the nurse's attention to what he / she is about to administer! AND document, document, document!

Don’t forget to download my form describing “pre-operative” questions that you all should fill out and take to the hospital (or even to the doctor’s office)  Even keep a copy in your pocket or pocketbook.  The list may seem a little long and doesn’t cover all the issues by any means but having all these questions answered might just save your life.