O C T O B E R 2 0 1 5 O U T P A T I E N TS U R G E R Y. N E T 1 5
sy was to be done
on the left lung.
"The patient men-
tioned offhand that
she thought it was
supposed to be the
left side, not the
right," says Tania
Daniels, PT, MBA,
vice president of
patient safety at the
Minnesota Hospital
Association. "The surgical nurse heard this and circled back to the original notes
from the clinic. She found that the notes from the hospital provider listed the
wrong side."
The surgical nurse spoke up and told the physician immediately after discov-
ering the error, ensuring he performed the procedure correctly. The physician
was grateful for the nurse's input and thanked her after she spoke up, says Ms.
Daniels. He reinforced the hospital's culture of safety, which prevented the
wrong-site surgery from occurring.
Easier said than done
Never events, despite their name, still happen. Why? Most patient safety experts
agree that the largest single contributing factor in these catastrophes is that the
OR lacks a culture of safety in which all staff members feel comfortable and
have the knowledge to speak up if something is wrong, says Spence Byrum,
CEO and co-founder of HRS Consulting. "You need an environment where the
surgical team is on the same page," he says. "They're communicating in an open
environment, and when there's something wrong, any member can speak up."
z CULTURE CHANGE Having surgeons lead the time out — while
encouraging staff to speak up during the case — can increase OR safety.
Pamela
Bevelhymer,
RN,
BSN
