Medical Error: Operation Room

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Table of Contents

Indirect Cause
Communication
Policy Problems
Lack of Resources
Checks and Balances
Conclusion
References

In ancient times healthcare was a trial and error process. No one fully understood the scientific basis of healthcare. There were a lot of superstitious practices involved in treating sick people. But when in the aftermath of the modern age, the man began a more scientific approach to life and healthcare. Hospitals were built, and doctors were trained not only to deal with minor healthcare issues but also more complicated tasks such as surgery.

Nevertheless, breakthroughs in the field of medicine have not yet eradicated errors in medical care such as the activities performed inside the operating room. One of the best examples to illustrate the cause and effect of medical error in surgery is the case of Tampa surgeon Rolando Sanchez who wrongly amputated the left leg of Willie King.

It was on February 20, 1995, when Dr. Sanchez was supposed to amputate the right leg of Mr. King but ended up amputating the left leg” (Banja, 205, p.9). It was not the simple case of having an incompetent doctor in the person of Dr. Sanchez; it was the result of errors made by many people (Banja, 2005, p.9). It was the result of a series of unfortunate events.

It is clear from this case study that the negative impact of medical error can result in the pain and suffering of many people (Dhillon, 2003, p.10). Consider its impact on the quality of life of Mr. King, who ended up having both his legs amputated. He could have managed with one leg and walk using crutches but with both legs gone he had to get used to a life on a wheelchair.

It was reported that Mr. King did no sue the hospital and Dr. Sanchez. However, documents were obtained showing that the hospital paid Mr. King $900,000 and the medical malpractice insurer of Dr. Sanchez paid an additional $250,000 (Banja, 2005, p.10). This goes to show the effect of medical error.

It is not only the patient who will suffer but also the hospital and the healthcare system in general. Money is wasted on suing the doctors and hospitals, and even if there is no legal battle as seen in this case, nevertheless money was spent for the wrong reason when it could have been used to improve hospital facilities (Abele, 2004, p.8).

Indirect Cause

According to experts: “There is no isolated case of an accident… there are multiple contributors to accidents, only jointly are these causes sufficient in itself to create an accident” (Banja, 2005, p.10). In the case above study, Dr. Sanchez is a competent surgeon, but it was revealed later on that there were errors made in communication, recording, and the lack of checks and balances in the system.

It has to be pointed out that the series of unfortunate events can happen before surgery. There is a great deal of preparation that has to be completed before a major operation. One of these is drug ordering and dispensing. If the drugs used in the operating table is not what the surgeon requested, then one can just imagine the adverse effect it can have on the patient. The chemical can cause serious harm to the body.

Incorrect records can be a major source of error. The recording of data is important, and there must be a way to secure the records as well as having an efficient way to retrieve it when needed. The error can be in the data collection process wherein names are misspelled, and names of drugs and medicines are not correctly recorded. As a result, the nurses or doctors who relied on these records can easily make mistakes and endanger the lives of the patients.

Communication

Communication is important because healthcare givers should not assume that everything will go according to plan. It is important for nurses and technicians to communicate with each other. It is also important to have certainty that critical messages reached the intended recipient.

However, nurses are sometimes hesitant to inform surgeons of a problem especially when it requires them to point out an error that has been committed by the surgeon. Most of the time, nurses will opt to go through the chain of command (Carroll, 2009, p.97). But this is not the practical course of action.

Policy Problems

An error can be the result of poor planning and also the creation of a policy that is full of flaws. The only reason why the error did not surface early on in the absence of triggering factors. One of the triggering factors is the sudden surge of patients. In small hospitals such as in rural areas, it is not expected to have multiple patients at the same time.

But what will happen if a group of tourists converged in the area and encountered a vehicular accident? The result would be a sudden increase in the number of patients that can easily overwhelm the staff (Senders, 1991, p.38). This problem, however, is not limited to small hospitals. Even in well-equipped big city hospitals, a weakness in the system goes undetected until a series of events forces it to come to the surface.

Consider for instance the effect of a blackout in the area. Does the hospital have the capability to deal with this problem? If not, then the system can be overburdened and the equipment in the operating room can be compromised by the lack of electrical power.

Lack of Resources

Common causes of errors can be attributed to the lack of resources as seen in the following observations:

financially unstable hospitals are error-prone and dangerous for surgery;
hospitals provide little money and effort when it comes to error prevention;
hospitals are hesitant to use information technology such as computerized data management (Clifton, 2009, p.84).

It is important to look into legislative changes that are needed to force hospitals to put up the money needed to upgrade their system. If the data shows that hospitals are not inclined to make investments to reduce the risk of errors, then something has to be done before it is too late. This can be achieved by working with local government to help them asses the situation and make recommendations (Jenicek, 2011, p.5).

Checks and Balances

It is important that the hospital review the specific responsibilities of all the people involved in the operating room including the support group such as nurses and technicians who will help in preparing the room for surgery (Seth, Morris, & Zaslau, 2008, p.5). They need to be aware of everything. It is not enough to simply do the things that they were told.

They have to learn how to communicate if they discover some inconsistencies. In the case of Mr. King, a nurse discovered the error but failed to follow-up on the information that she passed on to another nurse. It is also important to make everyone involved to understand their specific accountabilities (Sharpe, 2004, p.43). Everyone is accountable to the hospital and the patients.

In this regard, they will have to learn to go beyond what is expected. They must do their job well and have a positive outlook regarding the workplace. Thus, the flow of communication enables them to share information, and as a result, they can react quickly to any problem before it turns into a full-blown crisis.

Finally, there must be a major push towards reviewing the technical capabilities and experience of technicians, nurses, and even the surgeons. But most of the time the focus is on the doctors. Thus, the incompetence of technicians is easily overlooked. Consider the case of a medical error involving an x-ray view box. It is common practice to use the x-ray view box and an x-ray film containing CT scan images of the problem area of the patient’s body.

In this case, the view box is supposed to help the doctor determine what has to be done in a surgery requiring the removal of half of a woman’s skull to relieve the pressure that was caused by a severe stroke. But the technician responsible for putting th x-ray film on the x-ray viewing box made the error of placing the film backward. The surgeon has no way of knowing that the image that he was seeing was inverted.

The only way for him to have known is to look closely at the view box and notice the fine print was reversed. Since the surgeon did not know the blunder, he removed the wrong part of the skull. It is therefore important that technicians undergo extensive training for them to master the job that they need to perform (Berntsen, 2004, p.5). They need to hone their skills.

But more importantly, there is a need to train people with a view of prevention. If this mindset is established in hospitals, then it is expected to have regular drills and conduct practice sessions in dealing with some of the critical steps needed to prepare an operating room. In this manner flaws in the system will be exposed. Consider for instance the impact of preparing multiple operating rooms at the same time, each one having different sets of requirements.

There must be a government agency responsible for “checks and balances” to keep hospitals ready to deal with potential problems even before it occurs. The said government agency in charge of monitoring hospitals must develop standards that health institutions must adhere to. There must be constant visits to check the facilities and to review the capabilities of surgeons and support groups.

Conclusion

The root cause of the problem is the lack of commitment to preventing error. There is a big difference between fixing problems and having a system in place designed to prevent errors in the operating room. It is easy to understand this problem. Most hospitals are unwilling to spend money on improving their system. Part of the expense covers continuous training and honing skills.

The second major investment is in the use of new technology to improve communication and data management. There must also be a government agency tasked to monitor hospitals and determine if they are adhering to certain standards to prevent errors in the operating room.

If hospitals do not make it their top priority to prevent error, then the impact of medical malpractice can easily ruin them financially. There would be a public backlash. In short, the cost is much more if compared to spending money to enhance communication, records management and training.

References

Abele, J. (2004). Medical Errors and Litigation. AZ: Lawyers and Judges Publishing Company.

Banja, J. (2005). Medical Errors and Medical Narcissism. MA: Jones and Bartlett Publishers.

Berntsen, K. (2004). Patient’s Guide to Preventing Medical Error. Westport, CT: Praeger Publishers.

Carroll, R. (2009). Risk Management Handbook for Health Care Organizations. CAP Jossey-Bass.

Clifton, Guy. Flatlined: Resuscitating American Medicine. New Jersey: Rutgers University Press, 2009.

Dhillon, B. (2003). Human Reliability and Error in Medical System. New Jersey: World Scientific Publishing.

Jenicek, M. (2011). Medical Error and Harm: Understanding, Prevention and Control. New York: Taylor and Francis Group.

Sharpe, V. (2004). Accountability: Patient Safety and Policy Reform. Washington, D.C.: Georgetown University Press.

Senders, J. (1991). Human Error: Cause, Prediction and Reduction. New Jersey: Lawrence Erlbaum.

Seth, K., Morris, J., & Zaslau, S. (2008). Blueprints Surgery. MD: Lippincott Williams & Wilkins.

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