Your Liability in the Operating Room
If you practice nursing in the operating room, you already may be aware that you have a higher chance of being involved in actions that lead to litigation than any of the other nursing professionals. This is true, not because surgical nurses are more negligent than their counterparts, but rather because more actions against physicians arise in the field of surgery. Therefore, nurses who have participated in surgical procedures are more likely to be called as witnesses and even defendants. For these reasons, it is important that you carefully evaluate the following:
I do not take any patient into the surgical suite unless we have located documentation of an informed consent discussion with the surgeon.
My institution has a written policy that sets forth guidelines for handling retained foreign bodies.
It is our institutional policy to perform needle, sponge, and instrument counts.
I never leave a patient unattended in the surgical suite.
After surgery, I do not leave patients until a recovery room nurse has assumed their care.
Any changes in the patient's condition are quickly reported to the appropriate physician and noted in my documentation.
No patients are taken into surgery until their wristbands are checked and confirmations of surgical procedure are made.
If any equipment malfunctions during a procedure, the serial number of the equipment is recorded on the patient's record.
Except in emergency situations, no surgical procedure is initiated until an appropriate history, physical, and preoperative diagnosis have been entered into the patient's chart.
I chart on a 24-hour clock basis.
The surgical record contains the following:
identity of the patient
the patient's chief complaint
vital signs and level of consciousness
allergies
the patient's medication routine
IV fluids and blood administered
all drugs administered
any unusual events and how they were managed
any staff changes (name of relief person when a nurse takes a break, etc.)
the time the patient arrives and departs
the patient's position, types of restraints, supports, and padding
skin condition and prep solution
location of grounding pads
specimens and cultures sent to the lab
dressings applied
tubes, catheters, and drains placed
The following equipment is available in our surgery suites:
call-in system
cardiac monitor
resuscitator
defibrillator
aspirator
thoracotomy set
tracheotomy set
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