1. Running Head: A Reflection Of My Day In The Or. . .

A time-out is to be conducted immediately prior to performance of the procedure, it is initiated by the nurse or technologist, it involves all personnel involved in the procedure, the team members agree to a minimum of patient identity, correct site, and correct procedure to be performed, and all of this information is documented in the record, including those involved and the duration of the time-out.

The current policy requires the attending surgeon mark the correct site for surgery with the patient confirming the site in the preoperative holding area prior to receiving any anesthesia. Currently a safety checklist is used during the time out process in the O.R. but the patient is sleeping. The expectation is the site marked by the surgeon and the patient will remain visible after the patient is drapped for the procedure. The National Patient Safety Agency (NPSA) in 2005 noted this to be an appropriate procedure.

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

In the case listed here Dr. Loren J. Borud was scheduled to perform surgery on Mr. Michael Hicks early on a Friday morning. The surgery was liposuction and a scar repair procedure. Dr. Loren informed the patient the procedure would take approximately ninety minutes, but

In 2008, it was estimated that “medical errors total more than $19.5 billion” (Andel, 2012, p. 12). It is important to address and solve this problem at this time because the National Quality Forums (NQF) “never events” considers such events. Never events are events that occur that should have never occurred in the first place. Reducing and eventually eliminating wrong site surgeries will help improve patient safety in the operating room and become a leading example in improving patient safety in all aspects of healthcare.

Wrong-site surgery is a serious and preventable occurrence, however, it continues to be a problem in

On September 28, when we went to Tripler Army Medical Center, I was placed in the Cardiac Ward. At that time, I was able to learn so many diagnosis dealing with the patients. The nurse had briefly explained what was going on with each individual patient and the type of treatments they are doing to help. She had also neatly clarified each medication she was giving them and told me exactly what it was used for. I was able to get an experience of hands on by taking a patient’s temperature. I had shadowed as she did so many things to make the patient feel comfortable and did everything to the best of her ability to make them happy. She had taught me how to record every piece of information about the patients on the computer by showing me what

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

Conversely, the How to Guide: Five Steps to Safer Surgery is an adjunct to the World Health Organization (WHO), Safe Surgery Saves Lives: The Second Global Patient Safety Challenge. In this, the primary goal is to confirm that surgical teams not only communicate, but follow safety standards in order to minimize common mistakes and insure the best outcome for surgical patients. The standards included in this literature emphasize, “improving anesthetic safety practices, ensuring surgery is undertaken on the correct part of the body, preventing surgical site infections, and improving communication and teamwork” (Beaumont & Russell, 2012). The actual checklist consists of the following 5-step process:

UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document

Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

According to a scientific study that originated in Japan, “dogs and their owners experience surges in oxytocin, a hormone responsible for maternal caring, when they look into each other’s eyes” (Ian). The same hormone has been shown to spike in mothers’ brains when they look into their children’s eyes. Perhaps, this hormone is the reason that dogs have been considered to be “man’s best friend” for years. Perhaps, dogs and humans are more similar than we’d like to think. Did you know, similar to humans and their races, there are hundreds of different dog breeds in the world? Every dog in the world, just like every human, is made up of its own characteristics and personalities. Ivan Pavlov didn’t have a particular fondness for dogs, but little did he know that through his experimentation with dogs and their neurological reflexes, he was going to reveal the similarities of conditioning abilities within animals and humans.

The long wait had finally paid off. Soon afterwards, two radiology techs came to my room, and brought me to have a CT scan done. By this time, I had begun to tremble uncontrollably, and for the CT scan I had to lay down on a freezing table while the machine passed over me. This did not take long, and I was soon wheeled back to my room. But before I had been pushed out of the room, one the techs gave me a blanket to put over the thin sheet I had been using. This was the one act of kindness that was shown to me during my hospital experience.