Patient Falls Off OR Table: System Error Or Human Error?
An anesthetized patient fell to the floor headfirst from an operating room table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head down position to facilitate the operation. Fortunately, no injury occurred.
The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient.
A follow -up story noted that the hospital has experienced 11 other major surgical errors in the last year including two instances of wrong-site surgery and a case in which five swabs were left inside a single patient.
An investigation by the hospital noted that the level of situational awareness of the operating room staff was inadequate, and teamwork and communication were poor. In addition, the safety culture within the operating room was described as not highly attuned to patient safety.
The staff was also distracted by mobile phone use and idle chatter.
Instead of addressing the obvious human errors such as failure to place the safety strap, which in U.S. hospitals is clearly the duty of the circulating nurse, the hospital's plan of correction focused on the following typical system-type corrections: