NURSING VIDEO

AORN NATIONAL TIME OUT DAY

15 DECEMBER 2009       EORNA

MEXICAN VIDEO NURSING

NURSING VIDEO

ARE WE NEGLIGENT ON THE OPERATION ROOM?

Three years have passed on 18 February since I've presented at the XIII AESOP Congress a communication on a topic that at first it was especially noticeable in the reality of Portuguese Operating Room nurses. It's true that nurses as Maria José Dias Pinheiro has warned for some time to its importance. The communication was headlined "ERRORS IN OR. A REALITY". That day a head nurse of the operating theater of a major national hospital commented negativly on my communication, saying that it had not addressed anything new. And he was right ... in part. I have not invented, nor was it meant, absolutely nothing. My statement was aimed, above all, an awareness action . That research was based on recommendations made by various American associations and by the WHO on safe practices.

I started that cold morning a little private battle, not seeking praise or personal recognition, but the concern at that time and still today, by reducing the incidence of adverse situations or errors in the operating theater.

  This 3 years led me to various places in the national geography, the neighbour Spain and as far away as Chile, to make submissions on this topic. The message in all cases was always the same: "Dear fellows, ... it's possible to reduce the number of errors in the Operating Room".

Safety is a fundamental principle in the service to patients who come to the operating theater, and therefore quality. Improve it requires a complex task that involves the entire system. It involves all the elements present in the operating theater, nurses, surgeons and anesthesiologists, and requires a real teamwork. We've got to be able to identify the actual and potential risks in patient safety and act accordingly in the application of effective criteria  to give solution to them.

The errors of health personnel are a major cause of death and injuries in industrialized countries. Our mistakes have been studied in recent years. The Medical Institute of the United States estimated that there are approximately 100,000 deaths per year directly related to errors of health personnel. In fact, only in the U.S. related deaths negligence occupy the eighth place in the rankings, ahead of pathologies such as AIDS, breast cancer or traffic accidents. It's not an insignificant problem.

To promote the safety of our patients in the operating theater, we carry out a series of actions to help prevent adverse effects. We must learn from our mistakes, improve reporting systems and away from outdated policies of the error concealment because of the fear of possible punitive consequences. All this with a national policy of no punishment. We need to investigate the incidents on surgery competently . Only then, assessing the reason for the errors, we can find flaws in the system and anticipate weaknesses.

In the operating theater the possibility of making a mistake is particularly high, and the consequences potentially catastrophic . According to a study in April 2006 conducted by the Agency of Health Research and Quality, the incidence of surgeries performed in the wrong location occurs in 1 in every 113,000 procedures. This same study estimates that at least 65% of cases the error could have been avoided if it had been established a Universal Protocol Verification Pre-surgical like "Time Out".

Despite the growing interest in patient safety, there is still a general lack of awareness about this problem. Or at least about put into practice a program that significantly limits the errors. The ability to learn from the experience is severely affected in many Portuguese hospitals by the absence of  a uniformed method of patient identification and surgical procedures. It is essential to understand the need for implementation of a universe Protocol Time Out in the hospital  that helps professionals to reduce the incidence of mistakes on the procedures, patients and surgical sites.

The effective reduction of these adverse events for patients requires a joint effort and conscious of all the elements that are directly or indirectly involved in the surgery. All without exception. Continuing to ignore the risks inherent to work neglecting the possibilities that we have in our power to prevent a substantial proportion of the errors, must be understood as an outright drop in our quality of care, one of the most important aspect in the times in which we live.

Over the past 3 years I've received hundreds of statements of support from colleagues, many pats on the back and harmonious words of the leaders. Little more in fact. Because the fundamental problem lies in the truth we will  have to improve things. In practice, despite the initial statements of support, suffered a drop from professionals (doctors and nurses) who saw the Protocol Time Out as something which required unproductive waste of time. Even the managers were unable or unwilling to incorporate this type of protocols in our day to day. We live in a world where productivity and, we like to say also,... the quality. To lose 10 seconds before each surgery to confirm the team Protocol Time Out seems, to some people, absolutely unforgivable.

Have you ever asked yourselves how far we, health professionals, we are not being negligent?

Recently it was reported in Spain the case of a child who has submitted to a surgery on the wrong eye. Make no mistake, such cases may be more common than we think. Examples, frankly, are not lacking. Although we have more knowledge of the various mistakes in other hospitals, we continue to a fat eye and, in many cases, we are confident that this will never happen ... not to us. Is this really so?. Had they not happened to us?. How many of the mistakes made in the operating theater are silenced by a staff that tries to avoid the penalty in the future?. Who did not ever have a scare, for example, directly connected with the side that is going to perform the surgery?. We understand that in each case silenced, we lose the opportunity to understand why this problem happened. Thus we can not properly study the factors leading to the error so we can devise real and appropriate. In most cases, a simple gesture, a simple Protocol  Time Out can reduce significantly the possibility of error in the Operating Room.

Whose responsibility when it makes a mistake?. The leadership that does not apply the standard time Out in the service or the nurse who makes the mistake?. No doubt it is a contentious issue. I say are the two ... When we make a mistake that could easily be avoided by the Protocol Time Out, the leadership is responsible for having sufficient knowledge (or at least should have them) and does not create or apply the standard. Is guilty of collusion with the situation. It is also responsible the nurse who makes the mistake, knowing that the existence of such protocols Time Out and does not require its application in day to day. There is responsibility of nurses, anesthesiologists and surgeons. Finally, all those who were aware of these protocols continue to devalue its application, simply for convenience, or because they think it is time lost.

Does "missing" 10 seconds to complete the Time Out time (patient, surgery and place) before the incision is not justified simply because not making a mistake that is potentially serious and who will suffer is the patient?. Do not forget that the real victim of a mistake made in the Operating Room is always the patient.

We want to be recognized as highly qualified and responsible. I firmly believe that nursing takes up a more important place and highlighted within the organizational structure of the health system. But in order to achieve these objectives which we long, and why we fight so much, we must understand that we also have a great responsibility in our work. Forget the possibility of improving the care we provide to our clients can only be considered negligence on our part.

On a personal level, I won the battle of conscience, but I feel that I missed the most important: the application of the Protocols Time Out. The AESOP (Association of Portuguese Nurses in Operating Room ), just this year launched an aggressive awareness campaign on secure practices . Once again succeeded in addressing facing a major problem in OR nursing . It seems to me that at this point no one should claim that ignores the international recommendations on safe practices. There is still much to do, but now, it really takes a commitment and support of all those who work in the OR. Think this is a goal of some is only a wrong philosophy.

Since the ancients said, “ERRARE HUMANUM EST, PERSEVERARE DIABOLICUM”