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Discussion

Missing ray tec's

I was informed at work that a nurse in good standing with over 20 years got royally screwed over. Apparently a count was off by one ray tec. This nurse called for an xray, surgeon said it was neg. pt. was good to go. Well... come to find out the ray tec was in the pt. for over a month, and the xray wasn't up high enough so it was missed. This nurse lost the 'right' to do certain things, i wont go into that just incase coworkers read on this site... anyway i'm rather a new just 3 months in the OR. I was wondering just when does the nurses responsiblity to the pt. end? Are we to watch where the flat plate is positioned or request to look at the xray? I just dont want something like that to happen to me. How can i protect myself from that situation?

I dont know if anything happened to the surgeon...

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Hey heartincalif.

I've worked in OR for over a year so i'm not exactly an expert but here goes:

The surgeon was informed, an x-ray was taken. This is the appropriate protocol at my hospital and according to ACORN standards. A search and x-ray was taken, which is also protocol. The scrub nurse was responsible as he/she informed the surgeon. My question is did the surgeon sign the count sheet? Was the missing swab recorded on the count? Was the team leader/ nurse running the OR department called into the theatre? If i were in this position these are all the things i'd be trying to organise.

My understanding is if the scrub nurse does all these things then he/she has demonstrated responsibility for an incorrect count according to ACORN, and it is really in the hands of the surgeon who decides to finish off the case even though a swab is missing.

I feel sorry for whoever was scrubbed because theres nothing worse than the feeling of losing an item. And to have your practice restricted even though an x-ray was taken sounds pretty harsh IMHO.

We don't know all the details of this case, but from what you've told us this RN did everything that she was supposed to do. I'd advise her to fight this restriction all the way to the top. It's not her job or expertise to read the X-ray or to know if the plate includes the area where the sponge was lost. It's her job to notify the surgeon of the missing item and call for the X-ray. Sounds like they're looking for a scapegoat for their own errors.

BTW, Scrubby, it's AORN, not ACORN (although I like ACORN better ;-) )

In Australia it's ACORN...Australian College of Operating Room Nurses....

from what you've told us this RN did everything that she was supposed to do... It's not her job or expertise to read the X-ray or to know if the plate includes the area where the sponge was lost. It's her job to notify the surgeon of the missing item and call for the X-ray. Sounds like they're looking for a scapegoat .

agreed. My sympathies to this nurse, who is getting hosed.Linda

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