Quote from Jolie
Just another great day at work for you!
Incident reports should simply state the facts without assigning blame.
Assigning blame will, no doubt, come later, with all involved parties pointing fingers at everyone else.
Sounds like a good case for multi-disciplinary review, as this was clearly a systems error. Why did the person who accidentally thre the cord away not report that at the time? Why wasn't equipment checked the night before for that day's scheduled cases? Why wasn't there a back-up available in house for a vital piece of equipment? Why didn't the materials manager verify that s/he had the correct cord before the patient was medicated?
Plenty of blame to go around, but like with med errors, it usually runs down hill to the nurse caring for the patient at the time.
No, blame not for the report. Our morning meetings consist of "mistakes" and blame for the mistakes. Names aren't mentioned, but we have been told that checking everything before a case is the circulator's responsibility. With 20 minutes every morning, how is there time to check every case and test every piece of equipment for the day? We have nurses quitting, and have you ever heard of an OR with only 9 rooms with 5 RN openings for jobs?
To answer your questions:
Why did the person who accidentally thre the cord away not report that at the time? She apologized and said that she "forgot".
Why wasn't equipment checked the night before for that day's scheduled cases? Good question - not enough staff.
Why wasn't there a back-up available in house for a vital piece of equipment? Exactly. Materials manager said there is a back-up, but it couldn't be found! Many times we only have one of a piece of equipment.
Why didn't the materials manager verify that s/he had the correct cord before the patient was medicated? We will be told that's not her job, it's the circulator's job.
By the way, we are in the middle of construction, and equipment has to be moved every single day to new storage locations. Most of the equipment isn't even on the same floor - that's when we can find it.