The importance of error reporting

AORN Journal, Sept, 2007 by Connie Dyer

In reading the article "Factors influencing perioperative nurses' error reporting preferences" (Vol 85, March 2007), I determined that a very important point needs to be addressed more thoroughly--that the nurse, ethically, is the patient's advocate. Considering this as a standard of nursing requires that any event or incident that can potentially or definitely hamper the patient's progress or wellness must be reported and analyzed for several reasons:

* Future care of the patient may depend on the report.

* If the patient suffers an untoward outcome, information about the incident is valuable.

* Reporting is not a matter of "getting someone in trouble"; it is a matter of preventing the same incident from occurring in the future.

* If no one is aware that the event occurred, there is no way to discuss and improve our practice and the practice of the team.

* In a court of law, omitting the documentation of an error can have very serious consequences.

* If something is not documented, it implies that it did not happen. This sends a false message regarding the honesty and integrity of nursing documentation.

I would recommend finding a neutral way for reporting incidents and calling them not "errors" but "events." They are not willful mistakes meant to do harm. Others can profit from the discussion of an incident and learn from the measures used to prevent the incident from happening again.

Because of busy OR schedules, I do not believe an "end-of-case pause" is realistic. Anesthesia personnel are at a critical point, making sure the patient is breathing and that the patient's vital signs are good enough so that he or she can be transported to the post-anesthesia care unit. The surgeon probably is hurrying to get to the next procedure or to go to his or her office. The rest of the team is helping to move the patient and get ready for the next procedure. This is not a good time for an objective discussion.

CONNIE DYER

RN, CLNC

YORK, PA