In the video “Just a Routine Operation” by Laedal Medical Human Factors in Patient Safety, Martin Bromiley shares his personal experience of ignored safety issues that resulted in losing his wife Elaine. Among many, failed team collaboration and ineffective communication between health care members led to such tragedy.
Breakdown in team collaboration involving the lack of decision-making process, leadership, situation awareness, and prioritization took Elaine’s life away. Despite the fact that Elaine’s oxygen level fell down to 40% within four minutes into the surgery, it took 35 minutes for the healthcare team to decide to let her “wake up naturally” (Rogers, 2011). None of them recognized the situation as emergency nor took a leadership …show more content…
When three nurses were called into the operating room, they followed their nursing process and reacted quickly. One nurse prepared tracheostomy and another nurse reserved a bed in intensive care unit (ICU) (Rogers, 2011). However, tracheostomy was not used because of the nurse’s non-assertive communication. Another nurse cancelled the bed in ICU upon seeing physicians’ disapproving face of her call. The physicians and specialists were not open to suggestions and did not respect nurses’ professional role in healthcare. Mutual respect and trust enable clear interpretation and explicit communications. It is also nurse’s professional responsibility to ensure patient safety even if that requires identifying health care errors made by physicians (Ballard 2003). If the nurse was assertive of what should be done immediately and spoke up to the physicians, tracheostomy could have been used to ensure patient’s oxygen level and could have prevented further brain damage. If that nurse did not cancel the bed in ICU, the patient could have received critical care immediately out of the attempted surgery. If only there was effective communication between fellow colleagues in the operating room, things could have turned out differently. Hence, it is not surprising to find out that “…communication failures as the leading root cause for medication errors, delays in treatment, and wrong-site surgeries,
Breakdown in team collaboration involving the lack of decision-making process, leadership, situation awareness, and prioritization took Elaine’s life away. Despite the fact that Elaine’s oxygen level fell down to 40% within four minutes into the surgery, it took 35 minutes for the healthcare team to decide to let her “wake up naturally” (Rogers, 2011). None of them recognized the situation as emergency nor took a leadership …show more content…
When three nurses were called into the operating room, they followed their nursing process and reacted quickly. One nurse prepared tracheostomy and another nurse reserved a bed in intensive care unit (ICU) (Rogers, 2011). However, tracheostomy was not used because of the nurse’s non-assertive communication. Another nurse cancelled the bed in ICU upon seeing physicians’ disapproving face of her call. The physicians and specialists were not open to suggestions and did not respect nurses’ professional role in healthcare. Mutual respect and trust enable clear interpretation and explicit communications. It is also nurse’s professional responsibility to ensure patient safety even if that requires identifying health care errors made by physicians (Ballard 2003). If the nurse was assertive of what should be done immediately and spoke up to the physicians, tracheostomy could have been used to ensure patient’s oxygen level and could have prevented further brain damage. If that nurse did not cancel the bed in ICU, the patient could have received critical care immediately out of the attempted surgery. If only there was effective communication between fellow colleagues in the operating room, things could have turned out differently. Hence, it is not surprising to find out that “…communication failures as the leading root cause for medication errors, delays in treatment, and wrong-site surgeries,