What should Beth Israel nurses have done?
Write procedures for bringing in new equipment
The patient death that recently occurred at Beth Israel Hospital in Manhattan in New York City (see related story, p. 24) meets the criteria of a sentinel event as described by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, and has prompted hospitals around the country to examine their policies governing restrictions on sales reps’ behavior. Policies on continuing education for doctors and nurses are being revised as well.
Undereducation on new equipment has endangered accreditation and caused litigious situations before. Nearly a decade ago, seven patients died and 151 were injured during gall bladder surgery because their surgeons weren’t well trained in the use of a laparoscope; one had no instruction, and others had only one- or two-day seminars. Since then, the American Medical Association (AMA) has developed guidelines recommending not only that doctors take courses on new equipment and procedures, but that they demonstrate proficiency before they operate alone.
The guidelines are just that, however, not legal requirements. Hospitals set their own standards, and those standards are typically not as strict as the AMA’s, according to Randolph D. Smoak, MD, chairman of the AMA board.
"There should be procedures in place for bringing new equipment into a facility," says Aileen Killen, RN, PhD, CNOR, clinical director of perioperative services at Dartmouth-Hitchcock Medical Center in Lebanon, NH. "The equipment should not be used until everyone has been inserviced on it. The climate should be such that surgeons and nurses alike should feel comfortable saying, I’m not comfortable with this yet; I need to learn how to use this piece of equipment.’ That should be the way things go, especially if there’s other equipment that you’ve been using all along that does the same thing."
In Killen’s opinion, a managerial responsibility went by the boards if the nurses at Beth Israel did not feel comfortable saying, "I’ve not been inserviced on this piece of equipment, and I need to do that before using it on a patient."
She also notes that once the case gets into the OR, there needs to be trust among the team so nurses can say, "Something’s not right here," and other members of the team pay attention. "That apparently wasn’t the case at Beth Israel," she says.
Hospital Peer Review asked Killen why she thought some nurses act as those at Beth Israel did. "Some of the old indoctrination still exists," she explains. Nurses should feel comfortable questioning a surgeon who says everything’s OK when it’s not, Killen says. These days, the surgeon should not automatically have the last word. "I have seen instances where nurses didn’t feel they had the power to question surgeons," says Killen. "There has to be a climate in the institution where everyone’s opinion is valued on an equal basis. If one of the team says something’s not right, the rest of the team should stop and listen." That cultural atmosphere has to come from the top down — which, in the OR, means the nursing director and surgical director.
Should the nurses have walked out? "A nurse cannot walk out of the OR," says Killen. "His or her responsibility is to the patient, and whatever’s going on, it’s better to stay and not abandon him." But, she explains, the nurses could have called out for reinforcement to the manager or to the charge nurse to come into the room. "They should have said, Something’s not right here. Please come in.’"
"It doesn’t surprise me at all," says a nurse manager who comments on conditions of anonymity. She says verbal abuse in the OR is widespread, and the prevailing attitude is that the administration will side with physicians. Nurses say their hands are tied if they report that something doesn’t seem right when the physician says he or she has the situation under control. "The hospital wants physicians to bring in their patients," she says. "Even if a hospital has policies in place for when something is going wrong, it’s not always followed. The attitude often is, We wrote it but we don’t really mean it.’"
She goes on: "Surgery is still a male-dominated profession. I once saw a surgeon hit a pregnant nurse in the stomach during surgery because he didn’t like the way she handed instruments. She took up the issue with her boss, who was a male nurse director of the OR, and as soon as pressure was put on him by the administration, he didn’t take it any further. That’s out-and-out abuse." The pregnant nurse resigned and works elsewhere now. "Often, those instances are settled out of court," says the manager, "so there’s no legal record."
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