I have been an OR nurse for 10 years. I had an incident that has left me feeling like I should rethink my career choice. I have always been a conscientious and thorough somewhat obsessive compulsive RN. During a case, I totally forgot to prep the patient, the surgeon and tech draped the patient with ioban and surgical drapes. I realized the error as I began my documentation after the incision was made......Of course I informed the surgeon (and charge nurse/manager) of the error I am horrified. I just wanted to know if anyone has gone through a terrible "oops" moment and how you got over it? Thank you.
Jan 28, '12
It is a surprise that the surgeon and tech did not notice the lack of prep.. Afterward,
you did all the right things and it sure isn't something you should consider
changing your job over!
There has been studies done to check for the efficacy of pre op preps, and I
worked with a general surgeon years ago who did a blind study on patients that had
been prepped and those that had been not.. yes.. it really happened! Circulating nurse would pull a card prep or no prep and the patient either was prepped or not prepped
I don't even know the end result of his study, but I must say it made me really question
prep solutions etc.
Don't get me wrong, I am all for prepping, we usually use chlorhexadine, sometimes bridine. My point is that I don't think your patient will come to any dire harm because you didn't prep them and I bet they covered them with antibiotics as well.. Trust me you will never forget to prep again, and all of us OR nurses who have worked for any length of time
can tell you a nightmare or two!
KEEP ON OR NURSING!
Jan 29, '12
My friend, you cannot let one mistake of such a relatively small nature cause such an upstart. After all, you have a decade of experience under your belt....and if this is the mistake that makes you want to leave the specialty....I...I don't know what to say to make you change your mind.
However, for the sake of your sanity, I wish you would consider the following:
-- 99.8% of our patients receive massive amounts of antibiotics prior to incision.
-- Sterility, no matter what we say, is never guaranteed...is it? I mean, after all, we can't see the microbes, but we believe and establish a concept of sterility based upon what studies have shown us. We can never 100% say that our instruments are sterile....ever.
--The knife used to cut skin is used for exactly that purpose and then never used again during the course of the procedure. A second and even third knife is used for deep incision thereby limiting the exposure of skin microbes to the deeper tissues.
-- Most skin preps are not done properly and for the proper amount of time. Also, most preps are not allowed to dry (which is the actual kill time of prep) prior to incision. Yes, we like to think that this is not the case....but I'm willing to bet with your time in the OR, you have seen more than once surgeon actually blot a duraprep prep dry. Yeah...that kinda defeats the purpose, doesn't it?
--I'm sure you've been in "pour and cut" scenarios before. Hell, we're lucky if half the prep lands on the area they are going to cut.
I know that I'm not telling you anything you don't already know, but I would like to soothe you with a story that I'm glad to report is not truly mine.....but I know the individuals involved.
The long and short of the story:
30 someodd year old male comes in for spine surgery.
Flipped to table.
Tube is dislodged.
No one notices.
That is a mistake to make you rethink your career.
Missing a prep in the moment of pre-incision process? Not so much.
Jan 29, '12
I once pulled my sterile mayo over an undraped patient. Everyone has dumb moments. The fact that you realized it and immediately reported it says that you are where you should be. Sterile conscience is just that, a conscience, and the people who would scare me are the ones that won't say anything or worse just let it go.
Hopefully your OR has a good "there but for the grace of God go I" vibe. Every OR should have a zero negatives policy toward a mistake and just focus on rectifying it.
If you're like me, your head is thrumming with self recrimination, but if you're like me, you probably don't remember other staff's mistakes, so they probably don't remember yours either.
Be kind to yourself.
Feb 1, '12
My nurse manager once told me after a particularly bad experience that we work in a field where mistakes are going to happen and that some of them are going to be big ones, but that she decided early on that if she were going to be an effective nurse then she was going to have a set time to obsess/cry/grieve about a mistake. Her set time was 24 hours. After that you go back to work as a better nurse because that is a situation you are unlikely to find yourself in again.
PS - not prepping a patient isn't one of the big ones...
Feb 14, '12
Thank you all for your insight and words of advice.
. I learn something new everyday! Smiling...I will always remember to prep the patient BEFORE the incision......
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