Procedure Error: How Bad Is It?

[wanna_be]

It's the weekend and I haven't been able to sleep since this happened. Looking for some advice, insight, and possibly self-forgiveness?

Last week I was asked by one of the UAP to set up for an outpatient procedure that I had not been trained to set up for and had not done previously. It was a standard, low-risk procedure, and I was training another RN. I informed the UAP that I had not done this previously but would be happy to help set out the instruments with assistance. The UAP told me where the instruments were, where to place them, and as I was walking away she said, "don't forget the consent!".

We brought the patient back and while rooming the patient discovered the patient had an acute complaint. I stopped the intake for the procedure and took a brief history from the patient regarding their acute issue. The patient was in obvious pain. I advised the patient that addressing their acute complaint took precedence over performing the procedure, and I would inform the provider.

Myself and the RN trainee went to the provider and completed an SBAR handoff informing the provider that although the patient was scheduled for a procedure, they were in acute pain and I had informed the patient we would address this issue first. The provider verbalized understanding and stated he would evaluate the patient. I also informed the provider that I was unfamiliar with setting up for the planned procedure and would wait outside the room in case the provider needed further assistance.

While waiting outside the room, I received a triage call and advised the RN trainee to continue to wait for the provider and alert me if assistance was needed. A few minutes later, the RN trainee sent me a message and asked for my help getting some supplies. We walked into the room as the provider was initiating the procedure.

Soon after the patient left, the provider realized we had not gotten a signed consent from the patient. The provider stated he had reviewed the risks of the procedure with the patient verbally and the patient gave verbal consent. We agreed to call the patient to follow up that afternoon, but prior to doing so the patient called stating their pain had worsened and I triaged the patient and sent them to the ED. Fortunately it was determine their pain was unrelated to the procedure, but we completed an incident report d/t the circumstances and because a consent form was not signed.

I have been a nurse for almost a year and I just feel horrible about this. I know mistakes happen, but I feel there were many points in this event where I could have done the right thing and failed to do so--I should have gotten the consent initially, or spoken up and stopped the clinician when I saw the procedure was being initiated without written consent. I informed my manager of the event in great detail along with the incident report. I'm really scared I'm going to lose my job and I feel awful for not following procedure and ensuring this patient received the best quality care.

[Double-Helix, BSN, RN]

RNs should not obtain informed consent. That is the responsibility of the physician. Is that typical process for the place you're working?

[NurseCard, ADN]

Back when I worked with patients going to surgery, nurses would have

the patient sign the consent, but NOT before the doctor has explained

the procedure. The consent basically says "Dr Jones has explained to

me blank procedure, and the risks associated with"...

That was ten years ago though.

[Double-Helix, BSN, RN]

Back when I worked with patients going to surgery, nurses would have

the patient sign the consent, but NOT before the doctor has explained

the procedure. The consent basically says "Dr Jones has explained to

me blank procedure, and the risks associated with"...

That was ten years ago though.

What concerns me is that the OP stated: "I should have gotten the consent initially".

This implies that OP thinks the "right" practice was to have the patient sign the consent form before the provider had even seen the patient, much less discussed the procedure. That is absolutely not the correct process.

Also, the physician didn't notice the missing consent until the patient was discharged. That means that no pre-procedure "Time-Out" took place to verify the correct patient, procedure, and documents were present. This is also non-compliant with Joint Commission requirements.

Wanna_be, did you realize that consent had not been obtained when you walked in and the procedure was being started? If you did, you're correct that you should have spoken up in the moment. Learn from this mistake and resolve to be more assertive in the future. If you didn't realize the physician didn't get consent, then it was an oversight, but the ultimate responsibility of ensuring consent was obtained belongs to the provider performing the procedure- not with you.

It sounds like your experience revealed a lot of flaws in the processes in place at your facility. Unless these are corrected, this situation has the potential to repeat itself.

[wanna_be]

I did not realize until after the procedure was completed. You are correct, at a facility where I previously worked it was the clinician's responsibility to obtain both written and verbal consent, which is why it slipped my mind. Discussed with my manger today; will use this to initiate better policies around consent for procedure. Thanks for you input, everyone.

[Here.I.Stand, BSN, RN]

I did not realize until after the procedure was completed. You are correct, at a facility where I previously worked it was the clinician's responsibility to obtain both written and verbal consent, which is why it slipped my mind. Discussed with my manger today; will use this to initiate better policies around consent for procedure. Thanks for you input, everyone.

That's not supposed to be a facility-specific thing; the provider is responsible for obtaining *informed consent.* And since they are reviewing the risks, benefits, alternatives, explaining the procedure etc. there really is no need for the RN to have the pt sign. Provider and pt should sign the form right then.

[KelRN215, BSN, RN]

Consent is the responsibility of the provider performing the procedure, NOT the RN. Procedural consent is the responsibility of the Surgeon. Anesthesia consent is the responsibility of the Anesthesiologist. (When I worked in the hospital, separate consents were required.)

[Rose_Queen, BSN, MSN, RN]

Soon after the patient left, the provider realized we had not gotten a signed consent from the patient.

It is not the responsibility of anyone but the provider to get informed consent. When anyone is witnessing a consent, all they are witnessing is the signature. However, it is the responsibility of everyone to ensure that all paperwork, including consents, is completed prior to a patient moving into a procedure room. It should also have been directly read from during the time out/universal protocol/procedure pause. This isn't any one single person's error; it is a combination of several errors that slipped through what should have been multiple safety checks.

I should have gotten the consent initially

No, that is not your responsibility. Again, the only one who can obtain informed consent for a procedure is the one doing the procedure (or, depending on policies, a partner in the group- such as Dr. X will do the procedure, but Dr. Y sees the patient during a previous visit and gets consent at that time). Whoever took the patient to the procedure room should have verified that consents were complete prior to moving into the room.

spoken up and stopped the clinician when I saw the procedure was being initiated without written consent

Had universal protocol been followed where the procedure should be read directly of off the consent, this wouldn't have even been an issue.

Hindsight is 20/20. Fortunately, the patient did not have any ill effects from this experience, but it should impress upon everyone the importance of consent verification and universal protocol.

[iluvivt, BSN, RN]

Informed. consent is a process .The provider must have a discussion with patient and discuss the risks,benefits and alternatives if any to the proposed surgery,treatment or procedure! Then the written consent is the legal document that a patient signs agreeing the treatment or surgery and verifying they understand the risks..If is often the responsibility of licensed personal to get the consent signed.Do not get the two confused