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