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Health Care Industry

Protecting patients from potential injuries

AORN Journal, May, 2004 by Ellen K. Murphy

Correct site identification and elimination of wrong site, wrong procedure, and wrong patient surgeries are a national patient safety goal of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The Joint Commission has recommended creation of a preoperative verification process, involving the patient in marking the surgical site, and implementing a time-out pause to verify the consistency of all site, procedure, and patient indicators one more time before a procedure begins. (1)

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Certainly, extra effort to ensure patient safety is warranted given the severity of wrong site, wrong procedure, or wrong patient surgery should it occur. As early as 1947, Judge Learned Hand prescribed that a reasonable person should take every precaution that is less burdensome than the frequency of an injury multiplied by the severity of the injury should it occur (United States v Carroll Towing Co, 159 F2d 169 [2d Cir 1947]). Very severe injuries thus require increased precautions even though they occur infrequently; however, less severe injuries require increased precaution as well. This article discusses those less severe injuries that may occur in the OR with more frequency. Facts from cases reported during the last two years were examined to identify injuries occurring in the OR that have resulted in litigation up to and including state appellate and supreme court decisions.

The LexisNexis database was searched for cases reported in the last two years (ie, February 2002 to February 2004) that contain the words operating room and nurse and negligence or malpractice. Seventy-eight cases were listed. In three instances, two cases dealt with the same situation, effectively yielding information about 75 cases. Of these, 44 concerned alleged intraoperative injury. The other 32 involved injuries occurring elsewhere, preoperatively or postoperatively, with operating room appearing as a part of the explanation of what happened but not as the location of the alleged malpractice (eg, workers compensation cases, delayed or erroneous preoperative diagnosis, postoperative complication unrelated to intraoperative care, and occasional criminal cases). The 44 injuries that allegedly occurred in the OR were further analyzed for the frequency and type of injury involved.

INDIVIDUAL ACTION OR INACTION

Twenty cases alleged errors in judgment or skill by the surgeon, anesthesia care provider, or perfusionist. No direct perioperative nurse role in causing or failing to prevent these injuries could be inferred from the case reports. Surgical injuries included

* air embolus and a transected artery during placement of a central venous catheter,

* failure to assess stenosis before initiating tracheostomy,

* a cut on a baby's finger after a cesarean section (C-section),

* a suture placed through a catheter during a bladder suspension procedure,

* puncture of a cribriform plate during septoplasty and functional endoscopic sinus surgery,

* incomplete decompression and near exsanguination during back surgery,

* cardiac arrest during valve replacement surgery, and

* several instances of perforated bowel during laparoscopic and laparotomy procedures.

Injuries allegedly caused by anesthesia care providers included

* perforated esophagus (ie, two cases);

* late arrival, causing a delay in performing an emergency C-section;

* failure to postpone an elective surgery despite a chart notation that the patient had suffered a transient ischemic attack the evening before surgery;

* failure to assess and treat respiratory distress immediately after extubation;

* placement of an esophageal stethoscope in the patient's left lung; and

* unassessed cardiac arrest. One case involved the conceded negligence of a perfusionist who recorded normal blood gas levels on his perfusion record despite laboratory reports of abnormal blood gas levels that were not assessed or treated by the perfusionist.

Although none of these case reports suggested direct involvement of perioperative nurses, perioperative managers may wish to work with their surgery and anesthesia counterparts to re-examine communication and credentialing systems within a context of "could this type of injury happen here?" Several of these cases involved communication breakdowns or credentialing issues.

TEAM ACTION OR INACTION WITH NURSE INVOLVEMENT

Of direct interest to perioperative nurses are the remaining 24 cases, which were categorized by type of injury and revealed a number of common issues, including

* consent (ie, four cases);

* retained foreign bodies (ie, four cases);

* pressure injuries related to positioning (ie, four cases);

* unavailable equipment or implant sizes (ie, four cases);

* medication errors (ie, three cases);

* infection (ie, three cases); and

* burns (ie, two cases).

A possible wrong procedure occurred in only two cases, and these more likely were cases of inadequate explanation before consent or inadequate consent documentation.

Health Care Industry

Protecting patients from potential injuries

AORN Journal, May, 2004 by Ellen K. Murphy

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