OR nurses

Specialties Operating Room

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What would happen to a circulator in your hospital if they went as far as to get the wrong patient onto the OR table before the patient was identified as the wrong one? This is as specific as I will get, reminding you that I am not an OR nurse,but in PACU.

Would you be terminated, forced to resign or suspended only?

I have seen the OR staff harassed into "hurry hurry" but I still think that the ID band check beforehand would avoid this. I know I can' speak from experience here, but in my dept we always(ALWAYS)check the ID band upon arrival, just afrer the O2 goes on.

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Sharann, difficult one to answer as it is not at all an "easy mistake to make" incident. I think one would have to be aware of the full circumstances under which such a mistake could happen and how far the procedure went . I have been in a situation where 2 patients in the receiving bay had the same name, roughly the same age ect. However as one of the checks I make is the consent form then I would know immediately if there was a problem. However if I did not do all my checks then an error could have easily happened and the only person to blame would have been me. I do not think I would have been fired though. I think I would have gotten a warning. However I am only guessing.

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I'm assuming the nurse wasn't the one who ultimately realized this wasn't the correct patient? The nurse would probably be disciplined but not fired. Mainly because this was a breakdown at many levels. Things differ at different hospitals but if one person screws up and this can happen, then something's wrong. Where I work, anesthesia would be responsible as well, for bringing in the wrong patient and not checking the ID band with the nurse.

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Agree... a very difficult mistake to make! (at least by our policies) Actually, if it's possible then maybe policies need to be reviewed?

I once had an instance where I set my room up with the assist of an observing nursing student for a bowel resection. When we went to holding it turned out that there were 2 pts with very similar names, both under the care of the same surgical group. Both charts were on the desk nest to each other I picked up the first chart I saw that said "bob" and "Dr Smith" and was expecting to talk to that pt- "oh that must be him in bed #4" The student realized right away that I was wrong as she was observing in day surgery when "bob #2" was admitted- "but that man's here for a different procedure" Had she not picked up on that, the first thing I would have looked for would have been diagnosis and consent and I would have spotted a problem before even saying hello. Consent, site form, pre-op check, introduction, name band, "tell me your name, your doctor, and what you're here for" all should be done before the pt leaves holding. In fact it's also done by the transport tech before the pt may leave day surgery or the nursing unit. So... a #1 unit nurse, #2 transporter, #3 holding nurse, #4 anesth person and, #5 circulator all making sure we have the right pt heading for the right case! All that before the surgeon comes into the room for "time out"!!

Not sure what the consequence would be, but with a safety net like that, I'd be mortified if it happened to me!

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Specializes in surgical, emergency.

I agree with the others.....tough call on how to react to this situation.

I think we all agree that there is obviously a flaw in the "system" that allowed that to happen in the first place!!

That's what incident reports are for,,,to allow an examination of the process and how to effect repairs.

I feel the pain with the 'hurry, hurry" situation. I think most of us have been pushed, sort of assembly line type feelings.

I've always said, that's when a mistake would happen, when you are rushed to the point that you are taken out of your routine.

Our policy is to ask the pt for two descripters (sp?) usually name and date of birth, both are on name bands and charts, which we keep right on the pt's cart. I also ask what are we doing, which naturally leads to any questions or concerns,,,,etc.

This all leads up to our "time out" when all the surgical team is in the room, but that is often after induction. Late I guess if there is a problem, but till the knife hits the skin, not too late, I guess.

The holding area nurse, transporters and anesthesia are also sources that should be checking identification all along the way.

Mike

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The OR nurse admitted that she had not checked the pts ID band in the holding area. She made the mistake herself.She just didn't check.It is scary how close these things can get.

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The OR nurse admitted that she had not checked the pts ID band in the holding area. She made the mistake herself.She just didn't check.It is scary how close these things can get.

Is she the only person responsible for checking the patient's ID?

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Is she the only person responsible for checking the patient's ID?

Absolutely not, however, the system is as such that the patient comeing from home first is checked in by the pre-op nurse, then is transferred down to a "pre-op holding" area, and THEN gets taken back by the OR nurse/team. My best guess is that the mihap occurred when the patient was in the holding area, immediately before going back to OR. I believe the system has some flaw, given the patient is in 3 areas prior tp OR. This nurse has been OR nursing for over 40years btw.

Thanks for the replies.

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Specializes in OR.
What would happen to a circulator in your hospital if they went as far as to get the wrong patient onto the OR table before the patient was identified as the wrong one? This is as specific as I will get, reminding you that I am not an OR nurse,but in PACU.

Would you be terminated, forced to resign or suspended only?

I have seen the OR staff harassed into "hurry hurry" but I still think that the ID band check beforehand would avoid this. I know I can' speak from experience here, but in my dept we always(ALWAYS)check the ID band upon arrival, just afrer the O2 goes on.

My OR does what's called a "time out" before the knife is dropped. Granted, some surgeon's are hyper and want to get moving. I've had to hide the scalpel on some of them!:rotfl: Also, in the holding area the circulator checks the ID band and record number and the surgeon's also have to come into holding and initial the area to be operated on. Again, it took a long while for some of them to quit complaining and just do it. You'd think they'd welcome any steps that 1) protect them(and us!) from a lawsuit!:rolleyes: and most importantly, protect the patient.
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My OR does what's called a "time out" before the knife is dropped. Granted, some surgeon's are hyper and want to get moving. I've had to hide the scalpel on some of them!:rotfl: Also, in the holding area the circulator checks the ID band and record number and the surgeon's also have to come into holding and initial the area to be operated on. Again, it took a long while for some of them to quit complaining and just do it. You'd think they'd welcome any steps that 1) protect them(and us!) from a lawsuit!:rolleyes: and most importantly, protect the patient.

That time out is a JCAHO requirement... I admit since I'm per diem I still sometimes tend to forget (rarely, though!) I usually do the time out as soon as the pt and surgeon are in the same room though, to get them before they get too impatient, but I catch them not paying attention very often! Do I have to raise my hand first? Jump up and down and wave my prep stick? Shoot off a flare? What does it take for them to shut up for 40 seconds in the name of pt safety/lawsuit cost containment (pick the motivator that applies)

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Greetings to all fellow OR nurses

l just finished a 5 month nursing fellowship program into the operating room. l am new to the process in the operating room but i make sure that i have the correct patient and i stop the non essential chit chat to make PAUSE FOR THE CAUSE.. AND I WAIT UNTIL SOMEONE SAYS yes to the surgery performed..

I KNOW THE HURRY HURRY mentality and i refuse to make a mistake because I know in myself if I rush I will make an error... JOINT COMMISSION is coming this month to my hospital. Should be interesting... I LIVE IN ANCHORAGE ALASKA..... ps we need nurses........

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Specializes in Telemetry, OR, ICU.

Obviously, the OR nurse, as well as CRNA, and/or Anesthesiologist did not do a complete pre-op interview w/patient before rolling back to the OR. BTW, the pre-op interview of please tell me your name [then verify w/arm band], any allergys [also verified by arm band], who is your surgeon today & what procedure are you having done [both verified by consent form] take no more than 5 minutes. I've never, ever taken the wrong patient to the OR. I have gone to the wrong pre-op room for my next patient, which I quickly realized.

Does bug the crap out of me sometimes how turnover time & getting the next patient [especially w/TF cases] is so rushed. :madface:

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