A recent question posed on the CRNAbiz forum:
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Question: surgery performed on the wrong extremity.
RN Circulator did not do Time Out. (She was busy getting “things” for the surgeon)
OR Tech, back turned to pt. MD Assistant (resident) assisted surgeon with draping the wrong extremity.(Correct limb had huge YES on it)
CRNA, claims she was busy, trying to get a good seal on her LMA, and was having BP problems.
After incident, hospital Administration asked RN, OR Tech and Resident to resign. Crna, is employee of group that contracts with hospital.
Should she also be made to resign?
I think yes, but the Chief Anesthesiologist feels it is too harsh a punishment.
Thoughts? .gif)
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I agree with your chief and in fact I do not think anyone should be fired or asked to resign, what does that accomplish ? Quality improvement should not be seen as punishment, but rather an opportunity to improve. Did they take away the surgeons privileges ?
Firing or forced resignation accomplishes nothing. Everyone involved should be counseled and I would expect they would become the ultimate “time out” team after what they experienced.
Dennis Gundersen
Terminating this team( based on the data presented) is totally inappropriate. These are not stupid, careless or uncaring professionals. If they are like most in HC, on a daily basis they focus all they have learned to helped patients and in the process, taken on personal risk unimaginable by any administrator or lawyer.
More to the point, the anesthetist, of all involved, was managing the airway; a critical task – far more critical than anything being done by anyone else in the room! They should not be punished. Determining what gets operated on is the surgeon’s role. They should be held to their responsibility.
In fact, staff with good records make even more careful and attentive staff if problems are turned into staff development opportunities. Punishment, especially termination, is counterproductive at every level and a very expensive act on the facility’s part. Replacing and orienting new staff will frequently cost more than the yearly salary of the individual staff. Anyone can make a mistake. Would a physician be terminated if they lost a patient? No. This incident look very small by comparison.
Resign? That is absolutely ridiculous. These poor people! the poor patients! Was the patient injured, what was the outcome?