Karen L. Chambers, CST, BA
HCS/545 Version 2
Monday July 4, 2011
Nothing Left Behind
What prompted me to select this topic is an article that I read online just within the past couple of weeks regarding a nurse’s suicide as a consequence of a medical error. Not only has this provided me with the topic for discussion of a situation occurring in health care facilities, but it allows for discussion and reinforcement of one of our topics this week of first victim and second victim.
Kimberly Hiatt had been an RN for 24 years, all having been time spent at the same facility caring for infants in an intensive care unit. On September14 she made a grave error and gave her patient (a child) 10 times the dose of calcium, which caused the untimely death of the 8 month old child, the eventual dismissal of Kimberly, the state nursing commission to investigate and eventually Kimberly’s suicide on April 3 this year. Many of her co-workers have stated that there was no need to severely punish Kimberly, she was doing a good job of punishing herself, and she was devastated and was not forgiving of her mistake.
The magnitude of this event only prompts many of us to seriously look at the statistics that exists surrounding medical errors. The Department of Health and Human Services’ Office of Inspector General conducted a study November 2010 which concluded 1 in 7 Medicare patients experience serious harm because of medical errors and hospital infections each year, and 180,000 patients die! These numbers are almost double the 98,000 deaths attributed to preventable errors in the 2000 report “To Err is Human” by the Institute of Medicine.
These problems are not isolated by any means; in another survey conducted among physicians 92 percent of them said they’d experienced a near miss, a minor error or a serious error and 57 percent confessed to a serious mistake. Of all of these, 2/3 of them reported anxiety about future errors and ½ reported decreased job confidence and satisfaction.
This incident and many more similar to it has sprouted many to carefully take a closer look at their facilities, their practices, their ethical behavior along with the changes in structure, culture and social responsibility to prevent such a horrific situation from happening again. As much as medical errors occur in doctor’s offices, laboratories, intensive care units and many more locations, one place in particular that is of high interest for me is the occurrence of retained surgical items.
Because of this problem a national surgical patient safety project to prevent retained surgical items has evolved. This problem has been with us since the practice of surgery began. Retained Surgical Items (RSI) is the preferred term. Surgical items fall under four groups: sponges, instruments, needles and miscellaneous small items. There are a minimum of 1500-2000 cases of RSI in the United States each year (reported incidents).
If we use Sir James Reason’s Swiss cheese analysis of the latent factors and failed defenses which contribute to error, these cases represent problems in communication between perioperative personnel and perioperative practices.
The most frequently retained items are sponges, which in every operating room throughout the country come in different sizes. There have also been cases of retained towels! The most common sites of these items left behind are the chest, abdomen, pelvis and the vagina. Nothing left behind organization has embarked on a mission of enlisting hospitals around the country to review their policies, evaluate technology and test new practices and processes of how they track surgical items. Because of this endeavor, many hospitals developed a manual that delineates counting practices, along with a system called Sponge ACCOUNTing.
The Institute of Medicine’s report To Err is Human it spoke on three domains of care: Safe Care, Standardized Care and Customized