Who is at fault?

  1. We have a diagnostic hyster, d&c, and thermal ablation scheduled. No breaks all morning. I have lunch, then asked to give lunch relief. I then have 30 mins before case begins. I am pulling all equip in the room, and scrub and I notice cord is gone to ablation unit. He calls materials manager to help look for it while I set up the room. Surgeon is pacing. Scrub comes back to room and tells me ok to get pt, cord is found.

    I do pre-op check, and anesthesia and I bring pt in. Whoops - scrub said materials manager got wrong cord, but there should be a back-up somewhere. Pt given versed, so I stay in room while scrub, materials, and now manager are running around looking for a back-up cord. Last RN who used the unit comes in - so sorry, but she accidently threw cord away!

    It is now almost 25 mins after case scheduled to begin. Everyone has given up, and we have to wait for a cord to come from another facility almost an hour away. Surgeon explains to pt that an item is missing for the case, and we have to take pt to PACU while waiting for the cord.

    Your thoughts?
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  2. 19 Comments

  3. by   babynurselsa
    Why does someone HAVE to be at fault?
    Sometimes things just don't go planned.
    Good Luck
  4. by   KristinWW
    Incident report has to be completed - just wanted to get other opinions....
  5. by   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.
  6. by   babynurselsa
    An incident report is simply about stating the facts as they occurred. Facts being the operative word.
    Just write the IR as you observed it.
    Good luck
  7. by   KristinWW
    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.
  8. by   Jolie
    Run, Forest, Run!
  9. by   chartleypj
    Quote from Jolie

    Sounds like a good case for multi-disciplinary review, as this was clearly a systems error.
    These issues which occur in every OR every day around the world are precisely what creates nurse burnout.
    I agree, this is a systems issue and until some type of root cause analysis is done with concrete solutions implemented to improve efficiency, and productivity, resulting in improvement in staff morale, as well as patient and surgeon satisfaction, more nurses will leave nursing.

    PJ
  10. by   CHATSDALE
    had a similiar situation with a suction setup which had disposable and nondisposable plastic tubing..seems like the nondisposable was thrown out
    and when you had a pt is dire need you found that the machine was not usable b/c of missing tubing....FRUSTRATION
  11. by   ewattsjt
    I would have to agree that it looks more like a total systems error. Unfortunately, the facility will probably try to pin the blame and the RN is usually where the blame ends.

    Let us know where it went.
  12. by   KristinWW
    Quote from ewattsjt
    I would have to agree that it looks more like a total systems error. Unfortunately, the facility will probably try to pin the blame and the RN is usually where the blame ends.

    Let us know where it went.
    Ended up going nowhere! We got a general reprimand as a group about checking cases in the morning, as I said we would get, and everyone had to do an in-service on the thermal ablation and how we do not throw away the cord, and everyone had to sign. Get me outta here!
  13. by   Marie_LPN, RN
    This is why we have at least two of each machine, and test before pt. is brought into the room. Two harmonic scalpel units, two fluid management units, 6 Cell Savers, 6 Luxtec headlights, 3 Boston Scientific HTA machines.....
  14. by   Marie_LPN, RN
    Quote from Jolie
    Run, Forest, Run!
    And i second this advice.

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