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Discussion Question #1

Whatever you been diagnosed with that may lead to a surgical procedure (ex, appendix removed, or a quadruple bypass), any surgical procedure is a serious matter. The last thing anyone wants to hear following a surgery is that an error occurred.  But does that automatically mean your surgeon committed medical malpractice? Not necessarily.  Surgical malpractice is an act of negligence upon a patient by a surgeon, surgical nurse, anesthesiologist, surgical instrument tech or other medical staff involved in a surgical procedure. It occurs when a medical professional act in a manner which “deviates from the standard of care in the medical community.”

At the national level, our country is distinguished for its patchwork of medical care subsystems that can require patients to bounce around in a complex maze of providers as they seek effective and affordable care. Because of increased production demands, providers may be expected to give care in suboptimal working conditions, with decreased staff, and a shortage of physicians, which leads to fatigue and burnout. It should be no surprise that PAEs that harm patients are frighteningly common in this highly technical, rapidly changing, and poorly integrated industry. The picture is further complicated by a lack of transparency and limited accountability for errors that harm patients [2,3]

Most of surgical procedures performed each day in the United States are uneventful. Technology has helped minimize errors and improve patient recovery. Sometimes, however, some surgical procedures still go wrong, resulting in further harm to the patient. I manage a surgical instrument department in a hospital. Surgical instrument technicians (belonging to the sterile processing department or surgical technologists’ department) are part of allied professionals and work as part of an operations team in a health care organization. The department plays an essential role in patient safety as well as infection control. Sterile processing technicians operate the sterilizing equipment such as the autoclave that sterilizes instruments, equipment, etc. The technicians in the department must obey all hospital policies and are responsible for arranging the surgical equipment in the operating room. They must check, assemble, and adjust all medical tools to ensure that they are all functioning properly before the surgery begins. They must make sure all tools and equipment have been decontaminated and that the area is completely sterile before and after procedures.

There was an incident that I was directly involved with, an open-heart case. A technician assembled a chest retractor incorrectly, and this is an instrument that plays a key role in an open-heart case. In open-heart or heart transplant cases, every second and minute plays a role in the outcome of the procedure. Because a technician assembled the chest retractor wrong, and in an attempt to reassemble it in a rush, the instrument locked and would not function.  A patient was on the surgical table, his chest was wide open with no retractor to hold it and time was not on our side. Someone from the operation room (OR) called my work area for a replacement; thank God, we had a replacement to prevent a continuous downward series of events. However, with the all the time spent trying to reassemble the retractor, the patient got hurt from the improper ensemble of the retractor, lost a lot of blood and the surgical procedure time was extended.  The patient survived through that ordeal but that mistake should not had happened in the first place. And, yes, we got sued by the patient over the incident.

After the surgery, the surgeon was not happy about that mistake.  Management, including myself, got involved and created a back-up plan to address similar events as well as create some innovative ways to prepare an open-heart tray/set appropriately. Some of the rules and procedures that were implemented include: 1. All trays/sets needed for a surgical procedure should be ready and checked for its functioning in the operation room before a patient is placed on the surgical table. If this is done we can replace any instruments in a timely manner before the surgery; 2. We decided to make another tray/set available at all time just in case anything goes wrong; and 3. We went on to separate major instruments from the rest of instruments so more focus can be given to those instruments.

Unfortunate outcomes are no less stressful to the surgeon. This is an occasion to be honest and sympathetic with the patient. We should try to understand what happened and if possible, why it happened, without shifting blame. Most importantly, we should make sure that our patient understands the solution that is offered. Often from our experience we know that the problem is temporary and will settle with time. This calls for abundance of reassurance in the face of fear and anger from the patient’s side. A surgery should never be rushed as this is a life-boat and is to be set afloat only when all other options have dried up. (Bhattacharya, S. 2013).

In conclusion, “All men make mistakes, but a good man yields when he knows his course is wrong, and repairs the evil. The only crime is pride.”— Sophocles, Antigone”. Mistakes may not be a good thing but it gives room to revisit the situation and try to fix what went wrong to avoid the reoccurrence of such mistakes. In my case, I have learned a lot from that incident and have changed a lot as to how I approach anything I find myself doing.

NIV (John 8:7). “When they kept on questioning him, he straightened up and said to them, let anyone of you who is without a sin be the first to throw a stone at her”.



Bhattacharya, S. (2013). Wise to learn from others’ mistakes. Indian Journal of Plastic Surgery, 46(2), 165-166. doi:

Reid RO, Friedberg MW, Adams JL, et al. Associations between physician characteristics and quality of care. Arch Intern Med. 2010; 170: 1442–1449.

Levinson DR. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. DHHS, OIG. 2012, OEI-06-09-00091

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