Surgical Mistakes Part II

Surgical Mistakes, surgical mishaps, surgical errors, surgeries gone bad. Call it what you want but they are occurring and the numbers are rising tremendously. Just start surfing the web and read for yourself!

If you are a health care worker in an operating room, you know first hand what is really going on behind the closed doors! YOU are too scared to really say "anything" or YOU "might" lose your job. YOU are too scared to say "anything" because you "might" be ostracized by your fellow workers and you'll not be a part of the clique anymore. YOU are too scared to say "anything" because YOU "might" not get that leadership position in your national organization. YOU are too scared to say "anything" because you "might" get kicked out of nursing school and the list goes on and on! In an old BEATLES song, Strawberry Fields Forever, there are the words, "Living is easy with eyes closed," and so it is in the operating rooms. Eyes are closed to the suffering a patient and their family will go through once the patient leaves OR#4! That is IF the patient is still alive! Too often the mentality is, "Well, this case is done. Call for the next case cart."

Well, living is not easy for a "patient" if they are injured! Nor is living easy for the family or friends of the "injured" person, there are many consequences for everyone involved, not just for those who were "lucky" enough to survive! The emotional strain, the financial strain, and the physical strain will affect many! The spiritual strain is great too!

Studies show everyday that our healthcare is broken. Billions of dollars are being spent not only on the delivery of proper healthcare but also on healthcare to "FIX" the issues such as the needless infections, and the wrong site surgeries, to address the outcomes of wrong medications given to patients, and the wrong tests to wrong patients. The list of preventable issues is immense BUT they are ALL preventable! CMS (MEDICARE and MEDICAID also believe there are many "issues" which are preventable, that is why they are not reimbursing hospitals for "NEVER EVENTS" anymore.)

When I started my "Patient Advocacy Site"........be that it may, I was determined to write one discussion a week! I have so many operating room "issues" to share that these "issues" would fill up at least 10 published books! However, "just" my pain issues resulting from my surgery neck surgery have kept me from sitting still long enough at the computer to write a BLOG weekly! Yes, there are risks to surgeries BUT in my mind there are RISKS versus REASONABLE RISKS! My "risks" were explained to me by the surgeon's RN, if all the RISKS that I now present with had been explained to me by my surgeon, I would have had to say, "NO WAY, NO HOW" to surgery!

This brings me to a recent article I read in a local paper. I just mentioned how any surgical mishap affects a patient and their family or friends IF that patient survives the mishap! However, this recent article described how a three year old underwent "routine" surgery which went "horribly wrong", and the child died 23 days later! One year later, the father of the child took his own life! I can not imagine the mother's grief at not only losing her child but now to also lose her husband!

HMMMMMMMMMM, Strawberry Fields Forever! Surgical errors, surgical mishaps…what ever one calls "them" WILL happen again and again and again until national nursing organizations come together in HONEST conversation with national medical and surgical organizations! Whitewashing issues does not solve issues nor does it save lives or prevent the preventables!

The following are examples of some surgical / medical "mishaps.” I encourage everyone to do their own research! One article by a RN I have read recently, stated that "not all data is meaningful. Just because you can collect data doesn't mean you should. The key is to identify what data is truly meaningful. I say to this RN, that NOT ENOUGH attention is being paid to ALL of the data! To pick and choose what is and what is not only to attempt to prove "one's" theories is NOT real DATA!

PLEASE READ the FOLLOWING QUOTED "Issues"

(1) When a doctor is a patient: experiencing a medical error Doctors often describe a sense of shock when they experience the medical system from a patient's perspective. A gripping account of this phenomenon comes from Janice M. Scully, a Virginia internist who related a life-changing episode recently in the journal Medical Economics. The incident occurred almost four years ago and yet, Scully writes, "I'm still haunted by it." "Physically I've recovered as completely as possible, thanks to the doctors who treated me afterward. But it's the lingering emotional injury that still wakes me up at night," she says.

Nearly 100,000 patients die every year from medical errors. Countless others suffer severe and permanent, life-altering injuries as a result of medical mistakes. While these numbers are alarming, research indicates that only 15 to 20 percent of all medical errors are ever reported.

Posted by: Malpractice Boston, Nov 10, 2008 8:23:32 AM

(2) BACKGROUND: Prior data suggest that fatigue adversely affects patient safety and resident well-being. ACGME duty hour limitations were intended, in part, to reduce resident fatigue, but the factors that affect intern fatigue are unknown.

OBJECTIVE: To identify factors associated with intern fatigue following implementation of duty hour limitations.

DESIGN: Cross-sectional confidential survey of validated questions related to fatigue, sleep, and stress, as well as author-developed teamwork questions.

SUBJECTS: Interns in cognitive specialties at the University of California, San Francisco.

MEASUREMENTS: Univariate statistics characterized the distribution of responses. Pearson correlations elucidated bivariate relationships between fatigue and other variables. Multivariate linear regression models identified factors independently associated with fatigue, sleep, and stress.

RESULTS: Of 111 eligible interns, 66 responded (59%). In a regression analysis including gender, hours worked in the previous week, sleep quality, perceived stress, and teamwork, only poorer quality of sleep and greater perceived stress were significantly associated with fatigue (p < 0.001 and p = 0.02, respectively). To identify factors that may affect sleep, specifically duty hours and stress, a secondary model was constructed. Only greater perceived stress was significantly associated with diminished sleep quality (p = 0.04), and only poorer teamwork was significantly associated with perceived stress (p < 0.001). Working >80 h was not significantly associated with perceived stress, quality of sleep, or fatigue.

CONCLUSIONS: Simply decreasing the number of duty hours may be insufficient to reduce intern fatigue. Residency programs may need to incorporate programmatic changes to reduce stress, improve sleep quality, and foster teamwork in order to decrease intern fatigue and its deleterious consequences.

(3) Print Oct 22, 2008 10:54 pm US/Central Man's Surgery Performed On The Wrong Ankle

Reporting Dennis Douda (WCCO) A Minnesota man is permanently disabled because of a medical mistake at a Twin Cities hospital when a surgeon operated on the wrong body part. Surgical mistakes like that happened more than 200 times in Minnesota over the last five years.

"In 2008, this is one of those things that really just should not happen," said the patient's attorney Reid Rischmiller.

After years of pain from a warehouse work injury, a 57-year old Minneapolis man, who didn't want to be identified, decided to let doctors fuse his right ankle solidly together. His surgeon even signed the ankle with permanent marker moments before the operation last month.

Yet still, the surgeon somehow, cut into and irreversibly locked together the bones in his healthy left ankle.

(4) Surgery. 2006 Jul;140(1):25-33. Links Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, Studdert DM Brigham and Women's Hospital, Boston, Mass; Brigham and Women's Hospital and Center for Surgery and Public Health, Boston, Mass, USA.

BACKGROUND: The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention.

METHODS: We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded.

RESULTS: Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001). CONCLUSIONS: Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.

(5) There have been many on AHRQ's Web M&M. (www.webmm.ahrq.gov)

Listen to the Family CASE & COMMENTARY (June 2004)

Excerpt: "Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname."

Check the Wristband: CASE & COMMENTARY (July 2003)

Excerpt: "An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table." And there have been others in the news (see below). A superb article for teaching purposes is The Wrong Patient from Annals of Internal Medicine 2002 (abstract below).

Right? Left? Neither! CASE & COMMENTARY (May 2006)

Excerpt: "A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers."

_____________________________________

The "stories" and the numbers of the stories are ALL over the web! PLEASE take care dear patients so YOUR name or the name of your loved ones do not appear in the WEB obituaries before THEIR time!
_____________________________________

So dear "patients"...........be vigilant! DOWNLOAD and USE my sheet of PRE-OP Questions!

Take this sheet of filled out "questions" to the OR ........any OR or to the clinic or to the doctor's office. To anywhere YOU are having "ANYTHING" done!!! AND take down NAMES of everyone to whom you speak! Ask WHO is who! Are you an MD, are you a RN, what are your credentials? ASK! ASK! ASK! In the OR suites and ambulatory centers and offices, staff are often dressed alike. ONE cannot tell IF someone is a housekeeper or a doctor or etc! Be vigilant!

Blessings to you all,
God bless the USA,
God bless our troops,
Helen French RN, BSN