Break in sterile technique

[RN78910]

Hello,

I am a relatively new nurse. Roughly working as an RN for two years. I had a Pediatric patient who had their chest emergently opened at the bedside post op. It was kind of chaotic- too many chiefs not enough Indians type of chaotic in my opinion. A co-worker handed me an open package- at the time OR nurses and techs are at the bedside setting up to open the chest. Package was open (I think- as long as I am recalling this correctly. There is definitely a chance it was closed and I opened it) so I reached inside, flipped it over and realized it was a blue cloth. I said wait “what are you handing me- I touched this” at this point I think everyone’s adrenaline was pumping and I’m not sure if she heard me to which she said something about handing it to OR. I believe I then said said something again to the effect of “what are you handing me?” And someone else just chimes in and said hand it to the OR tech. At the time I was in the middle of a couple of different things as well as having two of the docs talking to me as we are watching the patient decompensate. I handed off the package and went back to what I was in the middle of doing- sending off labs I believe and getting a set up for cardiac lines. I cannot Begin to tell you how Much It has been eating me up that I probably ruined sterility going into a patients chest but also that this patient may have an SSI or worse outcome because I didn’t keep a cool head, clarify and speak up. I had over heard someone say “she put her hand on it, the girl” while I was with docs inside the patient room. I’m am holding Onto hope that Someone else witnessed it and kept it from touching anything else. Also I would hope if someone raised that concern they would have gotten a new set up started... but it was an emergency. patient is receiving post-op antibiotics, I believe ancef, Vanc and maybe cefepime?

my dilemma and concerns are:

1)patient outcome and safety. I am sick to my stomach that I didn’t take a step back and push for more clarification in the chaos. I am so worried about this little human

2) gossip- always. Where I work gossip about other nurses, their mistakes/oversights and spreading negativity is rampant. I’m fearful that I am now the topic of conversation and the new unit pariah that no one will trust with sick patients.

I am conflicted and I feel so incredibly guilty. Do I say something? Do I let it be? I am so so worried about this patient, that they’ll now get an SSI or worse. I’m also already pretty self conscious at my job because of it being more of a gossipy environment. This experience just makes me feel awful and guilty to begin with but the added stress of the dynamic on the floor makes me begin to worry even more. I don’t want to be thought less of or not respected. It’s definitely a mistake I will not be repeating

[SansNom]

Honestly, you're beating yourself up over something you no longer have any control of. I've seen similar things happen in codes and intense situations a few times, and all you can do is move forward. Sounds like the patient survived that situation, which is huge. Breaking sterile field doesn't mean the patient is guaranteed to get an infection, it just increases the risks. It's quite possible that nothing may come of it at all.

As for gossip, you might be imagining more gossip than is actually happening. Has anyone said anything to you about it? Have you overheard anyone talking about it? It may not be happening at all and you're just stressing about it for nothing. If it is happening, then confront it calmly and with a level head, owning up to what you know you actually did wrong.

Either way, it's a learning experience. Keep an eye on the patient and see how they turn out. Let this make you a better nurse. No one goes through their nursing career without mistakes, usually many. That's inevitable. What is avoidable is letting the mistakes define you and make you weaker.

[RN78910]

beyond beating myself up. Im home currently just physically ill because I’m so worried about the patient

as for the gossip I haven’t heard anyone say anything- yet. It happened yesterday. I’m just terrified that it will be spoken about and the topic of conversation and I don’t want to be thought less of. Should I say anything I guess is my real question? Do I discuss it with those who were present when it happened?

I think my other worry is if someone raised a concern, why wasn’t a new set up started immediately? Why did all those present decide to keep going? I know it was an emergency but Doesn’t that put all of us there in the wrong?

[Rose_Queen, BSN, MSN, RN]

2 hours ago, RN78910 said:

I think my other worry is if someone raised a concern, why wasn’t a new set up started immediately? Why did all those present decide to keep going? I know it was an emergency but Doesn’t that put all of us there in the wrong?

OR nurse chiming in here. First, a non-OR setting is not ideal for a surgical procedure- it’s cramped, it’s almost always an emergency of some type, and there’s a million people, many with tasks to do but also some just gawking.

Are these typically 100% sterile procedures? My bet would be only a small percentage don’t have a contamination of some sort. And that’s something we have to understand: emergencies aren’t ideal worlds. Sometimes all you can do is your best and hope the patient make sure through. We have a saying in the OR for these types of scenarios: we want the patient to live long enough to get the infection. These patients are the sickest of the sick and not doing anything and sometimes even taking the time to reset or run all the way to the OR for a replacement of something can negatively impact odds of survival.

That being said, if you were in doubt of the item’s sterility, the time to speak up is when you’re in doubt. It could be there’s a replacement readily available. It might be something nonessential that they can do without.

The key thing here is to make it a learning experience. Yes, you’ve expressed concern for the patient, but you also focus a lot on gossip. That means you are very concerned for yourself and your image here. That should truly be the tiniest bit of concern. And here’s the other thing- no one is perfect. A nurse who is able to speak up when they are concerned in a situation like this is worthy of respect rather than gossip. A nurse who stays silent is the opposite.

So what should you do in the future? Speak up if you think something is contaminated. If they move forward due to patient condition, then that’s what needs to happen and the break in technique can be addressed later. Help with crowd control- get rid of the gawkers. If they aren’t doing something essential in the room, get them out. Pushing meds, part of the surgical team, part of a code team- essential. The 3 people standing around “just in case they’re needed”? Get them out of the room. They can stand in the hallway and act as runners if supplies are needed, but the people in the room need to have a purpose to be there.

[RN78910]

I really appreciate your input!! Helps me feel a little better. Kicking myself in the *** for not reiterating and clarifying further I touched this And it is no longer sterile. My first emergent bedside experience off orientation, I let myself get caught up in the shuffle and didn’t keep my wits about me. Definitely lots learned from this experience. Thank you thank you

[RNNPICU, BSN, RN]

OP:

Also something to consider... if the patient is having an emergent bedside procedure a potential break in the sterile field is likely the least of the patient's issues at that time. Also, are 100% positive they used the drape you may have accidently touched? Are you 100% positive that the drape you may have touched was one the chest of the patient near the open chest? Someone obviously saw you open something and then instructed you to hand it to the tech. Likely there was something underneath the wrapped item that was sterile. Emergent bedside procedures have that risk since they are done in a non-sterile, non-controlled environment. If the patient develops an SSI, there are so many factors that it could be contributed to, primarily the bedside environment which would be the most likely potential cause.

PLease don't beat yourself up anymore, take time to decompress from a very stressful situation. You were not the only role in this emergency, there were many many many other chiefs as well.

[brownbook]

I work pre-op and PACU. We had an in service about what to do if a code blue is called in the OR, who should respond.

I asked something about....???? maybe masks, gloves, staff and supplies, breaking sterility, etc.. He said...forget about sterility in an emergency. We can always give the patient antibiotics later.

[K+MgSO4, BSN]

Please stop worrying about this. As others have said antibiotics are there for a reason, a bedside surgical procedure is as Hawkeye Peorifice put it in M*A*S*H meatball surgery. Its about saving a life, it is messy and in poor surroundings.

As it is already Christmas day here in Australia this post caused me to reflect on a Christmas day shift on the wards about 8 years ago. Young guy, trauma laportomy few days earlier, getting more and more distended and unwell, I go and assess his belly dressing is hanging to one side and his sutures have ripped and his intestines are popping out. I yell for help. The in charge dashes off to call the surgeon, next person comes in I send for saline they bring an IV bag because they didn't think to bring a bottle. It is cut open with my scissors last wiped with an alco wipe god knows when. I start pouring onto the guts, get towels to dam the flow off thr side of the bed. Surgical registrar appears sees what I am doing asks for more saline, kicks the break off the bed and on I hop. Pouring saline onto this kids belly as we fly round the tight corners of the hospital to theatre.

I had non sterile gloves on as I was pouring saline onto an abdomen as we went flying round a hospital and all of the air borne motes that sailed around.

The guy survived and never once did I question sterility. It was not the priority. Getting him to theatre was.

[Jeckrn1, ADN, BSN]

Don’t worry about this. If the patient had to have their chest opened in post-op sterile technique is the least of your worries. You need to think what would/could have happened if you had to go get a new drape. How many of the staff were scrubbed and gowned like they would have been in the OR? After working trauma in the ER & OR you just do your best to save the patients life. The surgeon knows the increased risk for infection in cases like this and would have treated the patient with antibiotics.

[Closed Account 12345]

You've received some great responses. I want to add that it's ok to ask your manager to arrange a team debriefing about the situation. What did we do well? What could we do better in a future similar situation? It sounds like you have been seriously affected by the situation, which was understandably traumatic. I think some closure and follow up would be beneficial.

[CCU BSN RN]

I've been in CCU 3ish years. Postop re-sternotomies still scare the daylights out of me. If your patient survived for a few hours afterward...you won. The alarm bells were sounded in time and we got back in there fast enough. If the surgeon re-opening the patient thought they'd survive until he could get them to the OR and operate in optimal conditions, he absolutely would've. Emergent bedside procedures are NEVER classified as completely sterile. That's why post op antibiotics are a thing. If your patient survives long enough to get an SSI...GOOD. I hope they don't get one, but that's fine if they do. We'll treat it. The point is, they didn't die THAT DAY. That's all you're hoping for when you do surgery outside an OR. Especially cardiothoracic surgery.

Ditto a debrief though. We have those after difficult cases, and it sounds like this ranks. Ask your manager if she's planning one and if not...ask her what merits a debrief in her mind. Does the patient have to die?