January 4, 2006 | Mark Paradies

Human Performance in the Medical Industry

Are you interested in real issues of human performance in the medical industry and why people make mistakes and cause sentinel events?

Then read this e-mail that was forwarded to me…

And post your comments here.

Please Post the following Question and Commentary:

How Long is Too Long for a Member of the Sterile Team to Remain Continuously Scrubbed into Surgery?

Although the public might not understand that medical professionals, including the Surgeon, must leave the OR briefly during lengthy Surgery, most conscientious practitioners realize that this is a normal safety measure necessary to combat fatigue. I am trying to get a consensus of feedback from those who routinely face this dilemma in the OR as to what time frame is universally accepted as the maximum period that any member of the sterile team can be expected to safely function while scrubbed into Surgery without a break. Although I am now in the “NIFA” training program to become a First Surgical Assist, even as a Surgical Technologist, performing the “scrub” role, I had to concentrate on anticipating the Surgeons needs during a case. After how long would you consider that scrub role jeopardized by fatigue to the point where I might have lost concentration and focus on the operation?

While a Surgeon can, and should, demand that the person assisting him is relieved, Nurses and Technicians fall under the control of OR Management which leaves us vulnerable to the vagaries of inappropriate OR coverage as determined by the Hospital. As a consequence of the Hospital “downsizing” to cut costs, redundancy of personnel has been severely limited to the point where during the off-shifts, especially at night and on weekends, there’s no free staff to break people out of Surgery for even a brief run to the bathroom! Calling in call team people to provide relief breaks is considered an unnecessary expense, despite the fact that there is a clearly established link between fatigue and medical errors. The sterile team scrubbed into Surgery are trapped without food or water until they are relieved; this also represents an unacceptable deprivation strain on the body. However, there are no safeguards within the existing US employment laws or OSHA standards to ensure that critical Hospital workers, including those in the OR, are not left for hours without a break. “Breaks are at the discretion of the employer.”

I was left stranded at the field without relief for 8, 10, and, at the worst occasion, 12 hours straight. These situations impacted my ability to concentrate as my blood sugar plummeted; each time I reported becoming sick, dizzy, and faint to the point of nearly passing out. When I complained that my condition in response to this hardship presented a danger to my patients, I was targeted for removal and then fired. Incidents where any member of the OR team is forced to remain on task for that long should be documented in an “Incident Report,” as an extreme of this magnitude presents an unacceptable danger to the patient. The Geneva Convention strictly prohibits such inhumane treatment of working POWs! How many normal humans are expected to go for 12 hours without water, food, or urination?

There is a lot of talk about medical errors, but far less mention of the toxic work environment that now encourages mistakes. This situation is getting steadily worse. While “At Will” employment laws silence those who dare to speak out, the lack of a humane break policy condones driving Hospital staff until they drop: is there any wonder that errors are on the increase? Little wonder that a sponge or an instrument is inadvertently left inside the patient when the scrub is almost comatose after a 12-hour ordeal in Surgery. All the cross-checking and safeguards are irrelevant if the Hospital staff are trying to function while so severely fatigued, hypovolemia, or hypoglycemic that they are at the point of either falling asleep or passing out. When will the various safety advocacy groups in the US finally address this very real problem and insist on proper protective legislation? There have been advances recently in limiting the Residents working hours and trying to stop mandated overtime for Nurses, but much more emphasis must be placed on eliminating unnecessary fatigue among our medical staff.

No one is more important than the patient unconscious on the OR table. For my very prestigious Maryland Hospital, the “Nursing Shortage” was a convenient excuse to justify unconscionable Managerial abuse that seriously endangered my patient in the OR. Doctors and Nurses face severe discipline when mistakes occur, but why isn’t a negligent Hospital policy that condones drastic staffing cutbacks ever recognized as the real culprit? In some cases administration even offers financial bonuses to encourage self-serving Managers to implement inadequate staff coverage. Then they fail to hold a repeatedly abusive Manager accountable when they drive dedicated staff until they drop. This Managerial excess is focused purely on saving money, not saving lives; we need proper safeguards in place to curb this negligent profiteering strategy before patients are harmed. Plus, when staff are courageous enough to come forward and expose a pattern of ongoing negligent practices, they must be protected from retaliation and taken seriously by accreditation agencies whose duty is to protect the public. No medical institution, no matter how iconic, prestigious, or powerful, should be immune from rigorous scrutiny. This lack of oversight encourages bending the rules, ignoring regulations, and cost-cutting, which is harmful to safe patient care.

Relentlessly abusive Managers are a valuable tool in facilitating staff downsizing without layoffs; I call this the spineless approach to cost-cutting, but it makes our Hospital working environment extremely dangerous for the patients. The current Nursing crisis has come about through this dangerous downsizing and the creation of a toxic work environment that is driving Nurses to leave their chosen profession because they refuse to take unnecessary risks. The US does not have a “Nursing Shortage” it has a “Nursing Exodus.” The US healthcare industry is still consistently expecting our medical professionals to take bigger risks by making do with unsafe staffing practices.

This issue desperately needs to be addressed, so please post comments here.

Kim L. Sanders-Fisher

Human Performance
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