From the front lines
Imagine this scenario. You are an operating room nurse and your patient’s surgery is finished. You and the team, including the surgeon, the anesthesiologist, and a surgical technician/scrub nurse are getting ready to move the patient from the operating room bed to the gurney. But the surgeon isn’t paying attention. The surgeon had spent most of the surgery complaining about hospital administration and he was still at it while you were moving the patient. This is common as the team talks about all sorts of things during surgery. The complaining? Yeah, that’s common too. What isn’t common is that as you were pulling the drawsheet with the patient tucked inside, the surgeon was putting the rollaboard under her and gave her such a hard push that you just about lost your balance and fell from the step-up stool onto the boom tower where much of the electronic equipment sits. Luckily, you caught yourself in a nick of time and were able to withstand the force of his push. It could have been a terrible mistake. You can’t even bring yourself to imagine the damage the team might have caused because you were doing something routine (we move patients from OR bed to gurney day in and day out) but the surgical team was paying more attention to the surgeon and his endless chatter about the hospital administration than they were to their patient. This is a true story. I was the operating room nurse. I felt horrible after we got her safely to the recovery room. I felt horrible for several reasons. First, I was mad at the surgeon for such carelessness on his part. Second, I was mad at myself for not doing better when I knew better, and third, I was mad because things like this happen all the time in the healthcare system but a close call seems to almost never be a reason to speak up. At least that is the culture. I started to wonder, “What would happen if the whole team took responsibility for an error?” At first, it looked like the surgeon’s fault and I was pissed, but the more I thought about it, the more it looked like a problem with the team and I was part of that team. I started to wonder, “What would happen if the whole team took responsibility for an error?” I mean, it’s no wonder we don’t talk about these things in the operating room because who do you think the hammer will come down on if there is a mistake made? What if it’s a big mistake and the patient suffers a catastrophic outcome or death? Well,…Litigation is a bitch and doctors are very careful these days to avoid it like the plague. Let’s say we reported the near-miss and we did something about it. Imagine if we talked about it as a team first, discussed what we did wrong without judgment, blame, or criticism. Hospital administrations are not too keen to ante up either. It could be very costly and you can’t always blame them because poor outcomes are a risk of any surgery. In fact, many a surgeon has been sued for mistakes that the patient knew from the outset were inherently risky. But a true medical error due to negligence? That can be devastating to reputations, careers, and the bottom line. That surgery room incident made me think long and hard about the solution to situations such as these. It made me envision a change in the culture of silence that seems embedded within healthcare in this country. I imagine that it’s the entire team who takes responsibility right from the start. Let’s say we reported the near-miss and we did something about it. Imagine if we talked about it as a team first, discussed what we did wrong without judgment, blame, or criticism. What could we have done better? How would we prevent this from happening in the future? That surgery room incident...made me envision a change in the culture of silence that seems embedded within healthcare in this country. Next, we can bring in our colleagues and educate them so that everyone gets to learn and, hopefully, not repeat the same mistake. Finally, as an organization, how about we don’t punish people for near misses or mistakes that don’t end in harm, disability, or death. Rather, we create a culture in which we look at near misses as opportunities to learn and do better. I believe that healthcare providers are, by and large, motivated and keen to do the right thing, but our culture of silence breeds distrust and blame, not growth and education. This is our opportunity to create better outcomes for our patients.