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Summary: During any surgical operation, there is an inherent "duty" owed to the patient that the operation will be carried out competently. This includes carrying out specified procedures and taking measures to prevent "foreign" objects from being left in the body cavity. In this case, during a coronary artery bypass grafting, a clamp slipped from the surgeon's sight. It would be found on x-ray later sitting behind the patient's heart. The patient was admitted for a routine coronary artery bypass grafting procedure. "What is coronary artery bypass surgery? A coronary artery bypass graft operation is a type of heart surgery. It is sometimes referred to as CABG or "cabbage." The surgery is done to reroute, or "bypass," blood around clogged arteries and improve the supply of blood and oxygen to the heart. These arteries are often clogged by the buildup over time of fat, cholesterol and other substances. The narrowing of these arteries is called atherosclerosis. It slows or stops the flow of blood through the heart's blood vessels and can lead to a heart attack."2 In the operating room, the procedure was carried out and per protocol, it was documented that all sponges and needles were accounted for by the nurses and physician. What was not accounted for and not "picked up" on until later was a clamp used during the procedure. Following a routine chest x-ray post-op, the clamp would be discovered resting in the pericardial sac, behind the patient's heart. At that time, no hospital protocol existed mandating "counts" on instruments during procedures (only sponges). "Materials counts are necessary to provide a standard of quality of care for the surgical patient and to provide a method of accounting for items placed on the sterile field for use on a surgical procedure."3 The patient would need to return to the Operating Room. A second thoracotomy was performed to remove the clamp left inside during the first procedure. The additional surgery went well; no further complications were noted. A lawsuit would be filed against both the physician and the nurses (as employees of the hospital). It alleged that their negligence had allowed the clamp to be left in the patient's body. This negligence then necessitated an additional operation, prolonged recovery time and placing the patient at risk of further complications and expense. The issue at hand was whether or not the clamp could have reasonably been left in the patient in the absence of negligence. It is clear, that if either the surgeon or nurses had knowledge of an article being left in a patient that standards of care would have been violated. This is usually applied in the case of sponges, however it applies to instruments as well. "In cases where there is an incorrect sponge count, wound closure absolutely must not be completed (unless the patient is unstable) until the missing sponge is accounted for. The surgeon should not pressure the nursing staff to ignore an incorrect count. If after appropriate steps have been taken to find the missing sponge or instrument and it is unsuccessful, every detail of the search should be documented and the surgery completed."4 If it was more likely that the clamp being "missed" would have only happened in the presence of "negligence conduct" then an award could in fact be made by a jury. Before the case could go to court, the circuit court of Jackson County granted directed verdicts for the defendants. The patient appealed. Questions to be answered: 1. Did the hospital share responsibility for the clamp "left" in the patient by the surgeon? 2. Could the operating room nurses be held responsible for the foreign object regardless of the fact there was no protocol requiring them to specifically account for it? The hospital is directly responsible for all events that occur while a patient is treated in their facility. In this case, included the actions or inactions of the nurses in the operating room. It would be up to the court and jury to determine if a greater amount of liability would be assigned to the surgeon or the nurses for their respective "roles" in the situation. When the surgeon was deposed and gave testimony, he clearly indicated that under "normal" circumstances a clamp would not be "missed." He went on to testify that is was clearly the responsibility of the operating room staff and physicians to evacuate the body of all foreign objects. "Counting is the legal responsibility of the surgical team. Each institution must develop a policy and procedure for such counts and should include the delineation of materials counted, interval of counts, mechanism for performing the count, and documentation of the count status on the intraoperative record. The responsibility for accurate sponge counts rests with the circulating and scrub nurses. The operating room nurses are charged with the responsibility to ensure that no foreign objects remain in the body at the conclusion of surgery."4 When queried on the specific circumstances of the operation, he stated it was "difficult" to miss a clamp in the area of the pericardium due to its size. This is a small cavity and relatively enclosed. The only explanation he offered as to the clamp being left in the patient was that "it slipped down where it could not be seen." Was the surgeon careless or did he get distracted and "lose track" of the clamp? Probably. Were the nurses and hospital held accountable for the mistake the surgeon made regardless? Yes. This underscores the fact that even in cases where the nurse has done "nothing wrong," he or she can still be sued for the actions or inactions of others. Related Nursing Malpractice Cases: May 23, 1999: Sponge Count Off, Patient Develops Sepsis, Surgeon Blames Nurse. Sponge Counts are a basic and critical safety measure during a surgical operation. In this case, the standard three counts were not performed. A sponge was left in the patient that would later lead to infection. When the issue went to court, the surgeon claimed "it was not his responsibility" to keep track of the sponges. Johnston v. Southwest Louisiana Assn. 693 So. 2d 1195 -LA (1997) http://www.nursefriendly.com/nursing/clinical.cases/052399.htm Related Link Sections: Cardiac Arrhythmias Links http://www.nursefriendly.com/nursing/directpatientcare/symptoms/cardiac.arrhythmias.htm Cardiac Catheterization (Diagnostic) Links http://www.nursefriendly.com/nursing/directpatientcare/tests/cardiac.catheterization.diagnostic.htm Cardiac Links, Direct Patient Care http://www.nursefriendly.com/nursing/directpatientcare/cardiac.htm Clinical Charting and Documentation, Nurses Notes: http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm Coronary Artery Bypass Grafting (CABG) Links http://www.nursefriendly.com/nursing/directpatientcare/cardiac/coronary.artery.bypass.grafting.cabg.htm Direct Patient Care Links http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm Ethics: http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm Informed Consent: http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.consent.medical.legal.htm Medical Legal Consulting Nurse Entrepreneurs: http://www.nursefriendly.com/nursing/ymedlegal.htm Operating Room (Surgical) Links http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htm Sources: 1. 40 RRNL 2 (July 1999) 2. The American Heart Association. 1999. Bypass Surgery, Coronary Artery: Retrieved July 4, 1999 from the World Wide Web: http://www.amhrt.org/Heart_and_Stroke_A_Z_Guide/bypass.html 3. San Antonio Chapter of AORN. No date given. "Counts, Sponge, Needle, Instrument." Retrieved May 23, 1999 from the World Wide Web: http://www.connecti.com/~remmert/p0008.txt 4. The Standard of Care. August 1998. " "Retained Surgical Foreign Body." Retrieved May 23, 1999 from the World Wide Web: http://www.standardofcare.com/publications/980801.htm
http://www.nursefriendly.com/nursing/clinical.cases/082999.htm Created on August 26, 1999
Last updated by Andrew Lopez, RN on Monday, January 25, 2010 |
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