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Slow Down to Avoid Care Delivery Mishaps

11/08/18

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By:

Elizabeth Shoaf, RN, MSN, CNOR, CSSM, Senior Consultant, Clinical Advisory Solutions

What does it take to actually slow down and not rush through important tasks? A simple decision? An outside force? Money? Sickness? There are so many things that can cause us to hit the brakes, but usually we like to keep our foot heavy on the gas pedal.

A few weeks ago while driving, I was literally and figuratively put into this situation. I am usually in a hurry and unfortunately, this often leads me to drive above posted speed limits. While I feel like I’m getting to my destination faster, there are many dangers and consequences to this behavior. The consequences came in the form of a police car behind me with blue lights flashing.

While I knew the road I was on very well, I was going at a speed that was faster than the posted speed limit. I was in the wrong. I was not being safe, and I was a hazard to the safety of others. Getting that warning and a lecture from the officer stuck with me and sparked many thoughts that related back to the health care profession. How often do we speed through our patient care tasks taking shortcuts; doing things a little bit differently than what the protocol states because it’s easier or faster?

As clinicians we may do this because we think our way is better and won’t be harmful to ourselves or others. Why do we think we are so special to not follow a law, a rule or a policy in the moment?

Early on in my perioperative training days, I remember an instance where speeding caused me to make a careless mistake. Room turnover was a focus of leadership, so time for the cleanup process was being monitored. On one of my shifts, I was scrubbing a laparoscopic urology procedure. While quickly cleaning up the back table in order to take the case cart to decontamination, I placed a Veress needle (a spring-loaded sharp needle used to inflate the abdominal cavity prior to inserting trocars) in the trash can instead of the sharps bin.

I knew that item was sharp when pressure was applied, but believed it was harmless when not active. I thought it was okay to throw the Veress needle in the trash versus the sharps bin because of the different charges to the hospital over the weight of the trash. After quickly taking my cart to decontamination, my preceptor and I began to prepare our next case cart. While reviewing the cart, my preceptor’s name was announced over the loud speaker to return to our OR immediately.

As we made our way to the OR, we observed a droplet trail of blood. The sight of blood was not unusual for us, however this trail was. We learned that the room attendant who empties the waste bins between cases had removed the bag and accidentally stabbed his hand with the pointy shaft of the Veress needle. I felt beyond terrible! My quick decision-making of sorting sharps combined with my overall novice knowledge of the OR caused someone harm. The red flags were there—we were all going too fast, I did not follow policy with my decision to discard that Veress needle and as a result, we were not being safe.

Like the laws we have in place against speeding to protect the traveling public, the instructions, guidelines, policies and protocols of health care facilities are in place for a reason—to keep medical mishaps from happening especially when we are caring for our patients.

Just as speeding is dangerous on the roads, it’s hazardous at the patient’s bedside, too. There may not be speed limit signs posted in the OR, the emergency department or in the hallways of the ICU, but there are checklists and policies that are there to ensure we don’t skip things or take shortcuts. Let’s not rush. Let’s slow down – resist the urge to speed—and follow the policies that put safety first.

About author. Elizabeth Shoaf has more than 13 years of experience in the health care industry, providing expertise around quality improvement initiatives, project management and staff development. Among her key achievements and accomplishments, Shoaf was one of the first in the world to earn the certified surgical services manager (CSSM) certification, she was recognized as a “Great 100 Nurse” by her North Carolina nurse peers, and she is a four-time published author in the AORN Journal. Prior to joining Vizient, Shoaf spent 10 years at Wake Forest Baptist Medical Center, most recently as perioperative clinical educator and quality and resource manager. In this role, she directed 18 training programs; introducing more than 200 new RNs to the intraoperative setting. She was a pioneer of the patient safety program, WakeWings, which changed the culture at Wake Forest and drove sentinel events to zero.

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