Friday, September 17, 2010

How Bureaucrats Would Close A Patient

The retained foreign body in a surgical patient.  That is one of a surgeon's worst fears and a hospital administrator's biggest public relations headaches.  Nobody wants it to happen.  Despite meticulous rules and multiple counting and recounting by the OR staff at the end of a case, this unfortunate event still occurs.  In our hospital's latest attempt to eliminate this scourge once and for all, the bureaucrats in the administration have devised a new set of rules for OR staff to follow before a surgical wound is allowed to close. 

Normally a surgeon only needs to say, "Stitch!" to declare he is ready to start closing. The new rules only require six additional steps that needs to be undertaken before the surgeon is handed his closing sutures.

1. The surgeon has to verbally announce in the OR that he is ready to close the patient.

2. No distractions allowed. That means the music is turned off in the OR. No superfluous conversations are permitted. Anesthesiologist, stop that yapping with your investment manager.

3. The nurses' counting of instruments cannot be interrupted.  Therefore nobody is allowed to pop their head in to ask about lunch breaks or scheduling conflicts.

4. The surgeon announces he is starting his wound exploration for any retained foreign body.

5. The surgeon announces he has finished his wound exploration.

6. The nurse announces that all instrument and sponge counts are correct.

7. At last the surgeon is given his closing sutures.

There is a checklist for every patient where all these steps have to be checked off.  The surgeon, nurse, and anesthesiologist all have to sign off on this checklist to verify that it took place.

Will this eliminate the possibility of retained foreign bodies in a patient?  Highly unlikely.  Let's face it, nobody intentionally leaves a sponge or instrument inside a patient unless under extraordinary circumstances ie/ trauma. Every surgeon finishes his case with counts confirmed correct by the nurses.  It is only when there is an unrecognized mistake in the counting that this accident can happen.  Ultimately, it is the quality of the count at the end that will catch a retained FB.  These elaborate new rules still depend on that action to prevent this error.  But since we're only doctors working in the OR, we're not the ones making the rules.  People who work nine to five and attend their committee meetings all day long without any clinical responsibilities are the ones calling the shots. That's how these idiotic rules come to be.

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