Assess, do not assume

AORN Journal,  March, 2008  by Nancy J. Girard

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On a very cold morning in December 2007, a terrible accident occurred in my home town. An alleged drunk driver who was going the wrong way on a divided major highway hit another car head on. The car that was hit contained several young adults. Rescue personnel, including four experienced emergency medical technicians (EMTs), arrived quickly to triage, treat, and transport the victims.

One of the young women in the car had a terrible head injury. An EMT observed her and made the assumption that the head injury was so severe that it had killed her. He declared her dead, covered her, and proceeded to care for the other victims. More than an hour later, it was noted that the head-injured woman was not dead; she had a pulse. She was rushed to the hospital, but she died the next day. (1)

Since this event occurred, weeks of controversy have ensued during which the fire chief, the head of the EMT training, the EMT instructors, and the public have tried to understand how this young woman could have been ignored for so long and, indeed, have been pronounced dead at the scene. Written protocols and instruction require EMTs to check for a pulse regardless of the appearance of the victim. All of the EMTs at the accident scene were trained by an excellent instructor who cannot understand why a student he trained did not check for a pulse. (1)

Why the EMT did not perform an assessment may never be known. Whether prompt action would have made any difference in the outcome will never be known. Because of this incident, the lives of the victim's family members and the EMT will never be the same.

WHY IS ASSESSMENT IGNORED?

As a nurse and a teacher, I found this story to be tragic for the EMT as well as for the victim. Every health care professional probably has had one lapse in judgement at sometime during his or her career. As happened with this vehicle accident, one assumption in lieu of an assessment can lead to disastrous results for a nurse as well as for a patient.

Physical assessment is a basic skill taught at every level of nursing. Patient assessment is required by every hospital, accrediting body, and institution. Perioperative nurses, like all nurses, have the best intentions, yet I have seen nurses minimize the importance of assessment or perform a very superficial assessment based on assumption. I also have seen busy nurses make assumptions about a patient based on information provided by technology alone.

FACTORS THAT AFFECT CARE DELIVERY

Weariness, physical conditions, emotional concerns, reliance on technology, and familiarity with a task can affect performance. These factors, as well as others not discussed here, can affect the safe care of a patient. Although there is no one solution for increasing the safety of patients, astute managers and peers should be aware of these factors during the work day.

WEARINESS. Long shifts, the need for constant awareness of the environment, lack of time to take brief breaks or eat, and the age of the perioperative nurse can contribute to weariness. A nurse may simply be exhausted. Personnel who are weary may tend to overlook simple actions, forget them, or just not think of them.

PHYSICAL CONDITION, Nurses themselves may not feel well, have chronic pain, or have other physical conditions that could affect their ability to provide care. Nurses also can be affected by the intake of drugs or alcohol, which certainly diminish performance.

EMOTIONAL CONCERNS. Nurses know that they should not take their personal lives to work, but sometimes personal circumstances are too stressful to ignore. Nurses who are going through emotional tragedies such as divorce, the death of a family member, or another devastating personal situation may not be capable of thinking critically enough to perform accurate assessments and may make assumptions about the patient.

FAMILIARITY WITH THE TASK. A task can become so familiar that is completed without thought or its importance becomes minimized in the day-to-day work of caring for surgical patients. For example, after checking the identification bands of hundreds of patients, a nurse may start to assume everything is correct. This obviously is a safety concern.

RELIANCE ON TECHNOLOGY. With the increasing use of technology to help assess and manage patients, information provided by machines often becomes the only method of assessment. Even with very reliable technology, a nurse should never rely exclusively on the information given without assessing the situation for himself or herself. For example, in one situation I was privy to, the automatic blood pressure technology was not working correctly. The machine showed a blood pressure of 100/60, well within safe limits for surgery. The patient's real blood pressure was 180/100--information the clinicians definitely needed to have in order to provide a safe procedure. No one noticed or questioned the malfunctioning machine even after six patients had identical vital sign readings. Although new technology is wonderful, nurses should never forget to use their own senses to see, smell, hear, and touch when assessing a patient. Technology is there to help with care, but nothing will ever replace personal assessment.