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|2012 YP Award Essay 3|
2012 Winner - Essay 3
The Doctors Company Foundation Young Physicians Patient Safety Award
It was five in the morning and I was on my first day of the labor and delivery service during my third year rotation. I convened with my new intern and a fellow medical student in the resident room where the intern quickly told us what we were expected to do and gave us a copy of the list of patients. Our job was to remove the staples from the post-Caesarean patients four days after their surgery. I had just learned how to remove staples the week before and had an idea of how to do the procedure, but was by no means a professional. I tried to explain this to the intern, but she said to page her if we had any problems and to get moving on the list because sign-out was soon. Then she scurried out of the room, leaving the other medical student and I to look at each other in mild panic and then get down to the business of trying to decipher the list. We scooted to the room of the first patient on the list that was four days post-Caesarean section and woke her up before we realized that we had forgotten the staple removal kit and both ran out to find it. We probably should have realized at this time we were over our heads and asked for help or guidance before starting our task, but both of us being eager to please did not want to disappoint the team so we carried on.
We found the kits after asking several nurses and hurried back to the patient’s room, where she had understandably fallen back asleep. We dutifully woke her back up and told her we were medical students who were going to remove her staples. She seemed confused but obligingly showed us her belly and we started the task of removing her staples. As neither of us had ever taken staples out ourselves before we were hesitant and slow and did not know exactly how the process should go or how the wounds should look. The new mother was patient with us, even though we could tell that we were causing her discomfort. We removed the staples and applied the steri-strips and left her to go back to sleep.
After this first patient we felt more confident and moved through the list without any problems, other than the discomfort we felt at waking the patient up at such an early hour. We removed the staples from four more patients and then went to the resident room to meet with the rest of the team. The residents started sign-out and we listened until our intern started talking about her patients. She read them by room number and I was confused as to why some of the room numbers had changed but did not question anyone. It was not until she read our first patient’s name and indicated that she was two days postpartum that I realized that I had made a colossal mistake. I quickly spoke up and verified that she was only two days postpartum and then declared that Katherine and I had mistakenly removed her staples. After a few moments of confusion and accusations, the team realized that the list Katherine received had not been updated and still had yesterday’s room numbers on it. Katherine and I had performed a procedure on a patient without verifying her name or medical identification number, and regrettably it was the wrong woman.
Unfortunately the team chose not to inform our attending physician or the patient of our mistake which I deeply regret, even more so than making the initial mistake. Our resident told us to go to clinic after rounds in the morning, so we gratefully left the floor for a few hours. When we returned it was time for attending rounds and Katherine and I took our place in the back of pack. When it came time to talk about our patient, the intern graciously attempted to take the blame for the mistake, but Katherine and I knew it was time to speak up and admit to our error.
The attending’s response was not calm, nor particularly productive, but the patient was informed of the error and made sure to be healing appropriately. She took the news with grace and I was lucky to be able to follow up with her on an outpatient basis and appreciate that she was recovering normally. After tempers had calmed we were able to discuss what had gone wrong and came up with the following rules to prevent this from occurring again: (1) always identify the patient and the procedure and obtain consent, (2) update any form of communication about patients so that every member of the team is always up to date on each patient (3) identify the capabilities of your team members and do not assign tasks of which they are incapable or uncomfortable performing (4) if a mistake is made, report it immediately.
This event sparked a personal transformation because it demonstrated that patients will trust me on the basis of my white coat and that I must always be extremely conscientious regarding patient care. I learned to never forget the basic tenets of performing a procedure: making sure that I have the correct patient and am performing the correct procedure. Although this incident might have been avoided had the list been updated correctly it does not excuse the fact that I did not follow basic safety rules, and as a result, a patient suffered the consequences. I feel exceptionally lucky that this patient was understanding and that this was a relatively minor error, however this rule has been seared in my brain and I always reinforce this guideline when working with other students in the hope that we can all avoid future errors similar to this one. ¨
*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.