A call to action for perioperative nurses - Patient Safety First

AORN Journal,  June, 2002  by Suzanne C. Beyea

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With each clinical encounter, perioperative nurses confront a variety of challenges in their efforts to keep patients safe and "first, do no harm." With the increasing complexity of patient care and advancing technological nature of perioperative settings, patient safety requires the collaborative efforts of practitioners at the sharp end of care. Their efforts must create clinical systems that minimize the risks of latent errors at the blunt end of care. Integral to these efforts is establishing systems that ensure practitioners at the sharp end receive adequate education and support to develop the knowledge and competence required to provide safe care.

ENSURING COMPETENCE

Clinical competence is a shared responsibility of educational programs, health care facilities, and practitioners. Individuals responsible for professional education programs must adequately screen applicants; monitor students' grades, performance, ability, and aptitude for a specific field; and graduate only individuals who have fully met the qualifications of the program. Health care facilities must monitor competency at the time of employment, assess competency on an ongoing basis, provide timely evaluation and feedback regarding performance, and address performance issues in an effective and timely manner. If educational programs and health care facilities fail their responsibilities, then unqualified or unsafe practitioners or professionals may be allowed to provide health care. This responsibility must be shared with practitioners who also must identify and address their own learning needs and any performance issues.

Each practitioner must be alert to potential system problems, performance issues, or clinical conditions that could result in medical errors. First and foremost, each practitioner must acknowledge the need for ongoing learning and pursue experiences that ensure competence in any skills performed. Perhaps the most important lesson is "knowing what you know, and knowing what you do not know." In other words, if a practitioner is asked to perform a skill or procedure for which he or she has limited skill, knowledge, or experience, it is his or her responsibility to acknowledge that gap. Furthermore, the practitioner should alert his or her immediate supervisor, and together, they can identify strategies to obtain the required education and/or experience.

Ensuring one's ongoing clinical competence is a shared responsibility between a health care facility and its employees. No professional can expect his or her employer to address all potential learning needs or interests. For example, if a practitioner is interested in learning more about leadership skills but this is not required in his or her current position, then it becomes the practitioner's responsibility to learn the necessary skills. In contrast, if ensuring laser safety is a job requirement, the facility undoubtedly will provide this educational content. Every practitioner has a responsibility to assess his or her competence level and ability to perform required skills in a safe manner. If the practitioner identifies any deficiencies, then he or she should pursue the appropriate learning experience. No practitioner should ever perform a procedure or provide care if he or she does not have adequate education and training.

Competent, knowledgeable practitioners serve as an invaluable resource in perioperative settings. Competent practitioners feel secure and can voice concerns about patient safety in a confident and assertive manner. Bringing a potential problem to the attention of others often can prevent a latent error from occurring. Competence "rubs off" as practitioners work together to help others attain and maintain high levels of competence and improve the overall quality of care. Of course, supportive clinical settings also provide an environment in which it is safe to voice concerns and address potential hazards.

ONE NURSE'S ACCOUNT

Charge nurse Carol Youngson cautioned that "Nursing isn't just a matter of fluffing pillows and providing TLC; it is literally a matter of life and death." (1) Youngson was in charge of the pediatric cardiac OR at the Health Sciences Centre in Winnipeg, Manitoba, when a cardiac surgeon was implicated in contributing to the death of 12 infants. Youngson related how "impressive credentials on paper don't always translate to consistently successful performances in the operating room." (2) She described the problems experienced with the surgeon's procedures.

   Almost immediately we began to see technical problems; for example, repairs
   failing and having to be redone, excessive bleeding, and unnecessarily long
   heart-pump runs. Cases we had always considered routine were turning into
   nightmares. If the children did survive surgery, they were being left with
   severe and life threatening complications. (3)

This courageous nurse and her fellow pediatric nurses reported these events to their nursing supervisors. Unfortunately, when the nursing supervisors conveyed these initial concerns to department heads, the issues were not addressed. Eventually, after 11 open heart procedures were performed on 10 patients with a resulting 50% mortality rate, the cardiac anesthesia care providers said they would not provide anesthesia for the surgeon's patients. This resulted in the formation of a committee to review the pediatric cardiac surgery program. The committee decided to limit the surgeon to performing surgery only on low-risk patients.