Christian Ray A.

Pasiliao BSN 3A
Concept: Perioperative Nursing Care

Surgical Errors Remain a Challenge In and

Out of the Operating Room

ScienceDaily (Nov. 17, 2009) — Despite a national focus on reducing

surgical errors, surgery-related adverse events continue to occur both inside
and outside the operating room, according to an analysis of events at
Veterans Health Administration Medical Centers published in the November
issue ofArchives of Surgery, one of the JAMA/Archives journals.

An estimated five to ten incorrect surgical procedures occur daily in the

United States, some with devastating effects, according to background
information in the article. Surgery can be performed on the wrong site,
wrong side of the body, using an incorrect procedure or on the wrong
patient. "The Veterans Health Administration developed and implemented a
pilot program to reduce the risk of incorrect surgical events in April 2002,
which resulted in the dissemination of a national directive in January 2003,"
the authors write. The rule was further updated in 2004.
Julia Neily, R.N., M.S., M.P.H., of Veterans Health Administration (VHA),
White River Junction, Vt., and colleagues reviewed reported surgical
adverse events occurring at 130 VHA facilities between January 2001 and
June 2006. Events were categorized by location (inside the operating room
vs. outside, at a location such as a procedure room at a clinic or at the
patient's bedside), specialty departments, body segments, severity and
several other characteristics.
Overall, the researchers reviewed 342 reported events, including 212 adverse
events (any surgical procedure performed unnecessarily, such as a procedure
performed on the wrong patient or wrong site) and 130 close calls (in which
a recognizable step toward an adverse event occurred but the patient was not
subjected to the unnecessary procedure). Of the adverse events, 108 (50.9
percent) occurred in an operating room and 104 (49.1 percent) occurred
elsewhere.
"When examining adverse events only, ophthalmology and invasive
radiology were the specialties associated with the most reports (45 [21.2
percent] each), whereas orthopedics was second to ophthalmology for the
number of reported adverse events occurring in the operating room," the
authors write. "Pulmonary medicine cases (such as wrong-side thoracentesis
[removing fluid from chest]) and wrong-site cases (such as wrong spinal
level) were associated with the most harm. The most common root cause of
events was communication (21.0 percent)."
The results indicate that communication problems often occur early in
surgical procedures, and interventions such as a final "time-out" moments
before incision may occur too late to correct them. "Incorrect surgical
procedures are not only an operating room challenge but also a challenge for
events occurring outside of the operating room," the authors conclude. "We
support earlier communication based on crew resource management to
prevent surgical adverse events."

Journal Reference:

1. Neily et al. Incorrect Surgical Procedures Within and Outside of the

Operating Room. Archives of Surgery, 2009; 144 (11): 1028
DOI: 10.1001/archsurg.2009.126
2. http://www.sciencedaily.com/releases/2009/11/091116163218.htm
Reaction

Surgical errors inside the operating room are a reality that should be
avoided as much as possible. Both the nurse and the doctor could
be sued for medical negligence even for a slightest mistake that
could either harm or kill the patient since they are both liable to
whatever would happen to their own patient. The Veterans Health
Administration conducted a study about the rising problem. Their
study leads them to the conclusion of communication as the main
reason of the errors committed by the surgeon. These include the
last part of the procedures in which the closing of the surgical site
in which they are too late to correct them. Poor communication
among the surgical team is weakness on the part of the surgical
team. World Health Organization (WHO) released a surgical
safety checklist and implementation manual by following a few
steps. Most of the part of this manual is done verbally, that is
why to minimize the most common and avoidable risks
endangering the lives and well-being of surgical patients
effective communication is essential. As a student nurse
communication on the surgical area is a bit hard on our part,
since we have to battle our anxieties of mistake, such as
wrong instrument identification and wrong counting of
equipments during closure, as well as our fears shyness
towards other members of the surgical team. In this we
student nurses should enhance our communication skills
through staying focused to what is already happening. We
should not just stay on one corner doing nothing. Next, we
should be listening attentively especially on the part of
confirmation of the patient, site and procedure. Now if we
didn’t hear it, we students should learn how to ask politely to
repeat what we weren’t clear. If we would be assigned to
reporting of the counted instruments we should report it on a
clear and loud voice for the whole surgical team to hear.
Communication is an essential component of a surgery but
often disregarded this leads to errors, but one with effective
communication comes often with success.