As I watched the televison program (ABC) on ‘checklists’ for doctors in surgery, I felt a sick feeling in the pit of my stomach. What in the world had we done to our healthcare system? The simple checklist has been around for years and years. All of a sudden, and, of recent, focus was towards mistakes and errors in surgery. Of course, hospitals, not being required to report medical errors in surgery, only lent to a misconception of how great the numbers were. Nevertheless, for more years than I can remember, the humming and buzzing within the health care environments was centered on these mistakes. All was hush hush. Did this hush hush come from the fear of law suits? More than likely that was part of it.

Within the last few years, I remember seeing on television a physician talking about a trend to be more honest with the patient. Honest in telling the patient about mistakes. Owning up for what errors happened. The physician, from my recall, was with the Veteran’s Administration Hospital, someplace on the East Coast, or Midwest. She clearly stated that was found related to less law suits when told upfront of the medical error. In other words, honesty often paid, and, not in law suits.

The ABC segment on July 1, 2004, stated a new set of requirements were in effect and had to be met by each hospital. These requirements focused on reducing the errors that happen in the operating room, many of which are deadly. Dr Massaro of the Joint Commission on Accreditation of Hospital Organizations (JCAHO) stated that something now could be done about these ‘wrong site surgical errors.’ Great, I thought. Now? Why not years ago? Regardless of what anyone said, the health care arena has been buzzing for years, related to mistakes and especially wrong site surgical procedures. Hospitals were never required to report these incidents.

JCAHO accredits hospitals. Hospitals go through a fairly strenuous inspection. Of course, the hospitals, have to pay a certain dollar amount, in order to have this inspection done. Interesting, in my humblest opining, I believe that our Federal government could do the same and not charge. But, then, there are so many aspects to this and certainly lobbying and politics enter and re-enter into the picture. So, what else is new?

I become so upset when I think of how health care has developed. I am not saying that there are no good doctors or nurses. I am just making a statement that our system is going down hill in some respects.

Operating on the wrong patient. How, in the world, could this happen, you are probably thinking. Well, it does happen. I remember, quite well, in the sixties, a friend of the family had surgery on the wrong knee. Sad, isn’t it? Sure is. But, consumer beware, it continues. Wrong site surgeries and mistakes in surgery continue and are alive and well. Unfortunately, the patients are not alive and well.

The ‘checklist’ is now in effect. The purpose is to reduce errors in the operating room. Again, I had to think, so what about all the mistakes that had been made over the years. Were they addressed by the hospitals so that mistakes would not happen again? Did anyone learn from the mistakes? .Was a mistake looked at in a manner of being a constructive education tool to prevent further incidents? Or, was the incident just hidden under the rug?

This new checklist has several parts.

** The body part is marked

** The nurse double checks the patient’s name and identification with all the lab

and hospital records.

** Before cutting on the patient, a ‘time out’ confirms that the right patient is on the

operating room table..

If anyone questions the accuracy of anything, everything is stopped and reviewed.

 

Once again, I get a sick feeling in the pit of my stomach. What and how, did we, as healthcare professionals go wrong?

Over the years, there was a piece of paper with a picture of the body. The surgical area was marked. Doctors often would diagram, in their notes, the area of surgery. Obviously, this was not enough. There was information all throughout the patient’s medical record of what and where was to be operated on. What caused all these medical errors? There are more reasons than one can think of, sad as it may be.

The nurse has always been responsible, (maybe not accountable, ) for ensuring the patient’s name matched all identification (lab, xray, etc.) In order to identify if this was done, or not, there was a ‘checklist.’ Yes, a checklist. How ironic. Furthermore, the checklist clearly stated this in detail. Ironic, indeed.

Again, I shuttered to think how sad it was that in 2004, steps were being taken, simple steps, as stated above, for medical errors that had been happening since the late sixties (that I can remember, in my professional career.) What took so long to address this, with a simple checklist. I was feeling somewhat embarrassed to say I was in the health care profession, as well as continuing to have a sick feeling in the pit of my stomach.

In the late sixties, I worked in surgery. Then we counted the number of sponges used for the surgical procedure. I can remember, very rigid rules. Counting before, during and after surgery.

Just take a minute and think about this time span. Over thirty years to get to a checklist? Personally, I don’t care what statistics say, I believe that this intervention, of a checklist, could have been done way before thirty years. But then, just my humble opinion.

A gentleman, in the area I live in, had surgery. The problem was a surgical instrument, of a fairly large size, was left inside this man. Sewn up and sent home, all packaged up with a metal surgical instrument. End result — this man’s life was no longer as it was before. Complication, after complication, never to be the same. (This received national media attention.) What have we done with our health care system? Where did we go wrong as a group of professionals, wanting to treat and cure patients. How did we get to the point of close to 98,000 deaths a year from medical errors? What went wrong? Can we ever change the system, to a level of improvement? Everyone is overloaded with work. Doctors and nurses alike are faced with double, triple the work they did before. And, it is not easy for them, especially those who really care about patients