SAFETY AND QUALITY

Csilla Orban Bonacci

 I choose surgery errors such as wrong site surgery.

According to the NQF they first coined the term "never events" in 2001 an organization in the USA that wants to ensure patient safety and quality care through public reporting. The NQF believes that "never events" are events that are preventable and can affect the credibility of a hospital. Over the years the NQF has identified numerous never events and these never events are broken down into categories: surgical, criminal, patient protection, and management radiologic just to name a few. 

Of the surgical never events we can find errors such as the wrong surgical procedure performed on the patient, surgery on the wrong body part, leaving objects inside the patient that were supposed to come out, and others. 

The nurse has a tremendous role in this case. This is why nurses working in the OR have to call a "time out" where everyone stops and identifies the patient and verifies why he or she is there and what procedure he or she needs to have done. Also, they count how many gauzes, sponges, and instruments they used and how many are left at the end of the procedure. All these are done to follow standards of care and guarantee patient safety. 

What contributes to surgical errors? A study in the past showed that Iran was the country with the highest number of surgical errors. In underdeveloped countries reporting errors is not common. Lack of properly trained surgeons, staff, surgeon-to-patient ratio, lack of instruments needed for surgery, etc. all contribute to surgical errors. 

As nurses, we can try our best to follow standards of care and even then we can make errors. Errors can be in the form of communication, system failure, due to fatigue, etc. It is up to us to speak up when we need help when we are tired when we need a break, when we cannot pick up a shift, when a machine is broken, or when we were not given a report. Being proactive helps nurses reduce medical errors and reduce patient safety events. 

We can avoid these kinds of surgical or medical errors by following the guidelines of mandatory reporting, working as a team, asking for help when we do not know something instead of just winging it, etc. 

Also, it is important to identify the patient by name and date of birth is possible. These are all simple guidelines we learned in nursing school that sometimes we can forget to do. We must not forget the most basic guidelines that ensure standard care.