The circulating nurse's role in error recovery in the cardiovascular OR.

Nursing surveillance, an essential component of perioperative practice, includes the detection of and recovery from errors. However, error recovery is considered routine during nursing care and may go under-recognized. This study assessed the types of errors or potential errors that were detected and recovered by the circulating nurse during care of patients undergoing coronary artery or valve surgery. From June to September 2010, perioperative nurses observed 18 surgical procedures. An average of 11.11 errors or incidents occurred per procedure; however, 77% of all incidents were intercepted and the other 23% were either mitigated or ameliorated so no adverse outcomes occurred. This study demonstrates that nurses play an important role in ensuring patient safety and reinforces the necessity of vigilance in the OR, especially in regard to aseptic technique and surgical prepping.

[1]  L. Leape Error in Medicine , 1994 .

[2]  D. Bates,et al.  The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care* , 2005, Critical care medicine.

[3]  Billings Ce,et al.  Some hopes and concerns regarding medical event-reporting systems: lessons from the NASA Aviation Safety Reporting System. , 1998 .

[4]  J. Cullen,et al.  Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. , 2011, AORN journal.

[5]  L. Aiken,et al.  Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. , 2002, JAMA.

[6]  K. Barker,et al.  Fundamentals of medication error research. , 1990, American journal of hospital pharmacy.

[7]  A. Gawlinski,et al.  A "near-miss" model for describing the nurse's role in the recovery of medical errors. , 2004, Journal of professional nursing : official journal of the American Association of Colleges of Nursing.

[8]  Anna Gawlinski,et al.  Strategies used by nurses to recover medical errors in an academic emergency department setting. , 2006, Applied nursing research : ANR.

[9]  D. Bates,et al.  Effect of reducing interns' work hours on serious medical errors in intensive care units. , 2004, The New England journal of medicine.

[10]  Tjerk W. van der Schaaf,et al.  Near miss reporting in the chemical process industry: An overview , 1995 .

[11]  H S Kaplan,et al.  The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. , 1998, Archives of pathology & laboratory medicine.

[12]  B. Cohoon Causes of near misses: perceptions of perioperative nurses. , 2011, AORN journal.

[13]  A. Gawlinski,et al.  Strategies used by critical care nurses to identify, interrupt, and correct medical errors. , 2010, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[14]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[15]  L. Christman Front Line of Defense: The Role of Nurses in Preventing Sentinel Events , 2003 .

[16]  Ann Page,et al.  Keeping patients safe. , 2011, Consumer reports.

[17]  C. Vincent Understanding and responding to adverse events. , 2003, The New England journal of medicine.

[18]  J Rasmussen,et al.  Human error and the problem of causality in analysis of accidents. , 1990, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[19]  T. Brennan,et al.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. , 1991, The New England journal of medicine.