This JUST recently happened to me and I'm beating myself up on it. It was a case in surgery where two different surgeons were working. When the first surgeon was done, the nurse that was giving me a break paged the other surgeon. I come back from my break and was given report. I waited about 20 minutes before calling into the other surgeons' OTHER room to ask a question. It sounded like they were busy so I got my question answered and hung up. Next thing I know, it's an hour and a half later. The surgeon is still NOT in this room and his patient is still under anesthesia. I finally go to the other room to see what is going on and the MD said he never got paged and he was just hanging out in this room and not ours bc we didn't call. Turns out, when the operator called to tell him to come to my or room, he cut her off and thought he was needed in his other room. A five hour procedure ended up being 7 because I didn't call in the room and ask if he was ready yet bc we were waiting on him. I felt so bad! Even the doc was telling me that he was at fault too. Today, I got called to my CC and he asked what happened and I told him what happened and it was my fault. I'm freaking out! Like, is this fireable? The patient did great under anesthesia and nothing bad happened but omg I just feel so bad still! This is the worst mistake I've ever made!
Sounds like an unfortunate collection of circumstances. I don't see how it's any one person's fault. The patient in OK. Hope you are OK, too.
Doubt it, since no patient harm.
I agree with halfboiled, no patient harm.
I work in the OR. When my patient is ready and the surgeon does not show up after paging, i usually ask somebody to go check on the surgeon. If it fails, I will call the charge nurse, express my concern, and ask for direction. I do so because i know sometimes the paging system does not go through. At least, I will try to investigate what is going on with the surgeon.
Out of curiosity, did anyone (like the CRNA or ST in your room) say anything when you guys are waiting for the surgeon for 90 minutes having the patient under anesthesia?
When the operator called him to tell him to come to the room "he cut her off". Sounds like he had a big part in this error!
I'm confused as to why he cut anyone off.
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