Discussion response Roselor

Preventing Wrong-Site Surgery

After watching the simulation of “The Wrong Body Part” and conducting my interviews, I discovered that these preventable errors were heartbreaking to the patients and their families. Wrong-site surgical procedures, including surgery on the wrong body part, the wrong side, or even the wrong patient, are considered never events because they are completely avoidable. Nonetheless, research suggests that they occur in approximately 1 out of 112,994 operations (Kwaan et al., 2006). The following recommendations and suggestions are designed to avoid these tragic errors and are grounded in the simulation analysis and the ideas introduced in Chapters 14 and 15.

Understanding the Root Causes

The literature has long suggested what simulation has demonstrated: wrong-site surgeries are typically caused by a series of mistakes. Rather, they occur when multiple failures interact: failures of communication, failures to provide effective verification, failures to have patients mark their locations, and cultures that make employees feel uncomfortable speaking out (Pennsylvania Patient Safety Authority, 2007). The worst part of this is that the errors often occur when procedures are in place, and it appears we are turning safety measures into a checklist rather than a set of measures to be taken.

My Key Recommendations

1. Make Patients Active Partners in Safety

The Joint Commission Universal Protocol should be implemented in healthcare facilities with real patient participation. Site verification is done with the patient awake and alert, and, wherever feasible, the patient should mark and point to the area with his fingers. Informed consent is not merely a legal defense; it is respecting patient autonomy and providing the patient with a full understanding of what will occur to his body, as Pozgar and Santucci (2019) emphasize. It is a biblical concept in Galatians 6:2: "Bear one another's burdens, and so fulfill the law of Christ" (ESV). Patients and healthcare providers should be co-creators of safety, not consumers of care.

1. Strengthen Informed Consent and Create a Culture of Safety

The Stover v. Surgeons case exemplifies the law regarding the inability of physicians to provide patients with proper information (Pozgar & Santucci, 2019). Surgeons must communicate with the patient in person with the use of anatomical diagrams, teach-backs, and call-outs to ensure that she is not in danger of continuing with surgery. This should also push towards the facilitation of an environment where everyone feels free to raise concerns when something appears wrong. Research by the Pennsylvania Patient Safety Authority in 2007 indicates that a significant percentage of wrong-site surgeries happen when those performing the procedure notice the mistake but seem powerless to do anything about it. The biblical wisdom is reflected in Proverbs 11:14: "Where there is no guidance, a people falls, but in an abundance of counselors there is safety" (ESV). Awareness of collective vigilance is a collective protective measure against individual mistakes.

1. Build System-Level Safeguards and Commit to Transparency

It is recommended that organizations have the following areas of protection in place: multiple levels of protection, including EHR alerts of inconsistency, two-clinician verification, photo-documentation of site marking, and periodic audits of adherence. It is an echo of the biblical necessity of prudent stewardship of Proverbs 14:15: "The prudent gives thought to his steps" (ESV). Organizations must report any errors committed. Chapter 14 states that patients are entitled to hear about any unexpected outcomes or errors (Pozgar and Santucci, 2019, p. 409). Ephesians 4:25 instructs us: "Therefore, having put away falsehood, let each one of you speak the truth with his neighbor" (ESV). By concealing the wrongdoings committed by medical workers, they ridicule the face of God in their patients.

The Biblical Worldview Perspective

Medical ethics, which are based on biblical teaching, are interwoven herein. The heart of the argument on informed consent and patient rights lies in the fact that all human beings are images of God (Genesis 1:27), and thus, they have a natural dignity and value. The teaching of Jesus in Matthew 7:12 is very literally applicable: whatever you do not want done to you, do it to them too (ESV). Patients should be treated by the medical staff in a way that is acceptable to them or their loved ones. The second main biblical value is that of stewardship, which reinforces the need to be stewardly of the gifts of medical knowledge and patient trust that God has bestowed upon us. "From everyone who has been given much, much will be demanded" (Luke 12:48, NIV).

Conclusion

Wrong-site surgery is an atrocious negation of the first principle of medicine, which is "do no harm." Besides the legal provisions and the systems reinforcements, medical professionals have an additional calling that is imbedded with biblical values of love, honesty, responsibility, and human dignity. We, perhaps in a more-than-vital sense, are showing how God loves and is faithful to our patients when we prioritize patient rights, achieve informed consent, and prevent medical errors. When we respect patient rights by obtaining informed consent and preventing medical errors, we are, in a way, sharing the love and faithfulness of God with our patients.

References

Kwaan, M. R., Studdert, D. M., Zinner, M. J., & Gawande, A. A. (2006). Incidence, patterns, and prevention of wrong-site surgery. Archives of Surgery, 141(4), 353-358. https://doi.org/10.1001/archsurg.141.4.353

Pennsylvania Patient Safety Authority. (2007). Doing the right things to correct wrong-site surgery. PA PSRS Patient Safety Advisory, 4(2), 29-35. https://patientsafety.pa.gov/ADVISORIES/Pages/2007...

Pozgar, G. D., & Santucci, N. M. (2019). Legal aspects of health care administration (13th ed.). Jones & Bartlett Learning.

The Holy Bible, English Standard Version. (2001). Crossway Bibles.