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2013 YP Award Essay 4
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2013 Winner - Essay 4

The Doctors Company Foundation Young Physicians Patient Safety Award

 

The case had gone well. The patient had tolerated anesthesia and the procedure without incident. The patient’s new prosthetic hip was in excellent position and placed without difficulty. As the resident began to close the wound, the entire operating room began to breathe a sigh of relief. The room was already running late and everyone present was set on expediting the room turnover process. The circulator and scrub technician had already contaminated their table in an effort to sterilize the instruments quickly for the next case. Anesthesia was on board with the fast-paced turnover plan, and the patient was very close to consciousness as the last staples were placed. As the dressing was being handed to the table, the attending surgeon proceeded to hastily use scissors to cut the antimicrobial adhesive drape and sleeve drapes from the elderly patient’s leg. In the hurry of the room, the surgeon proceeded to incise 11 inches of skin and superficial fascia from the lateral thigh in addition to the sleeve drapes.

 

As the mistake was realized, hemostasis was rapidly addressed with the few remaining sterile instruments and general anesthesia was once again induced. A plastics consultation was obtained and after 2 hours of approximating skin edges and sewing, the patient was left with an 11-inch jagged incision in addition to his initial 5-inch incision.

 

Postoperatively, the patient did not receive a satisfactory explanation or apology of the events that transpired in the operating room. The patient progressed well with physical therapy and on post-operative day number 3 the patient was ready for discharge to home even though he was still somewhat unsure of why he had 2 wounds which were not only disfiguring but also sites of significant pain and possible infection. In my selfish desire to receive a good evaluation from this surgeon, I hesitated to explain things more fully as I knew that the surgeon had already obtained legal counsel.

 

The surgical error of cutting through the patient’s skin with the drapes was a calamity. This patient placed his life and well-being into our hands, and we were too impatient to spend the extra fraction of a second to ensure that the drapes were separate from skin. Clearly the staff, including myself, needed to focus our undivided attention on the well-being of the patient rather than when we would finish the day. We needed to be ready to slow down at moments of potential danger.

 

This surgical error, however, pales in comparison to the communication error of not adequately discussing or apologizing for the error. Without a thorough discussion of the error, this patient will develop a generalized distrust of the surgeon and other medical professionals. Keeping the true course of these events secret also results in increased anxiety of the surgeon, a perpetual fear of litigation, and a tense patient-physician relationship.

 

This event and others like it inspired me to make a personal decision to not continue the same errors of impatience and impenitence as a few of my attendings. However, I find it shameful that several medical schools like my own did not have a patient safety curriculum. Such a system devoid of a curriculum on patient safety promotes the perpetuation of these medical errors. With the help of Dr. E, a trauma surgeon and director of surgical safety at a local hospital, we polled the medical students at school about their thoughts on incorporating patient safety into the curriculum. Over 80% of students shared similar sentiments and wanted to be taught about ideas like error causation and mitigation, human factor concepts, safety improvement concepts, systems theory and analysis, teamwork, and error disclosure and apology. With these results we were able to make a strong case to the curriculum committee, and the medical school agreed to incorporate patient safety into the curriculum.

 

It is my dream that now with this new curriculum, not only I but also my generation of young physicians will have a better understanding of the importance of patient safety. We would be ready to put the well-being of our patients ahead of our own schedules. We would be willing to admit when we had made a mistake and explain such incidents to our patients with our sincerest apologies. Such an understanding of patient safety among myself and my classmates would lead to a fewer mistakes, and a better, safer health care system.

*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.

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