Incident Reports

[partydoc]

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Ok, so your opinion really doesn't mean anything. As a resident you have to STFU and eat sh_t due to the constant "you'll be fired" hammer your residency director wields. As an attending with many years experience and many, many shi_t sandwiches later, this nonsense gets old. PainDrain, I feel for ya' man. If I could punch these c_unt nurses that you've talked about and get away with it, I would.

i cant be fired. im too valuable as a work force to my program, especially as a competent ca3

 

[Consigliere]

i cant be fired. im too valuable as a work force to my program, especially as a competent ca3

Ahhhh...the fallacy of the "too important." No one is too important, son.

 

[Promethean]

This is normal four you guys? I have never worked at a hospital that did a time out before induction, and we don't have a bunch of complications or problems from our "unsafe" practice. The time out is for the surgical procedure, and is performed before incision. These checklists before checklists are just plain ridiculous.

Actually, I take that back, our podiatrists like to time out before induction on their shockwaves for plantar fasciitis or Achilles tendonitis, but that's it.
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It was a high volume procedure area. Doing a time out upon entering the room became a necessity after a series of unfortunate events and near misses. The pre-op area was physically very far away from the OR and procedure rooms and the demands of room turn-over meant that the circulator didn't get to even see the patient before they were brought into the room. So, the time out upon entering the room was our first opportunity to be sure that we'd been brought the correct patient and that they were consented for the procedure we had set up to do for them. It is embarrassing how often (I'd say at least once a week?) that the poor resident who'd obtained the consent for the procedure had failed to inform the OR that the plan had changed and that we would need entirely different equipment/supplies than were required for the scheduled procedure.

I could go on and on about the ways that place was a set up for disasters. But I try not to reminisce too much. The PTSD is starting to fade as time goes by.

 

[GravelRider]

i cant be fired. im too valuable as a work force to my program, especially as a competent ca3

Change "too valuable" to "too cheap" and then it would be correct. Using a crna to replace your labor would cost a lot more money.

 

[doctalaughs]

So, when there are protocols that are in place for good reasons, and they are being ignored by people who think that such measures are nothing but obstructions put up by uppity nurses who enjoy throwing their weight around, what should be done? How can we have safe practice? How can we make the tools better so that they aren't used punitively? These are real, heartfelt questions.

I think most doctors, regardless of specialty would agree there are way too many useless protocols in place.

The main problems are:

1. Most protocols are put in place by people who aren't actually delivering the care (ie not the doctors)

2. Most protocols (although not all) are well intentioned but there is little effort to see if the implementation actually worked (ie actually reduced errors or did what they supposed to do)

3. Once a protocol is put into place it's almost impossible to remove.

4. More and more protocols are put in place not to improve patient care, but just to "check a box" for government regulations for billing. This in turn leads to administrative bloat and less efficient patient care.


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[Promethean]

I think most doctors, regardless of specialty would agree there are way too many useless protocols in place.

The main problems are:

1. Most protocols are put in place by people who aren't actually delivering the care (ie not the doctors)

2. Most protocols (although not all) are well intentioned but there is little effort to see if the implementation actually worked (ie actually reduced errors or did what they supposed to do)

3. Once a protocol is put into place it's almost impossible to remove.

4. More and more protocols are put in place not to improve patient care, but just to "check a box" for government regulations for billing. This in turn leads to administrative bloat and less efficient patient care.


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I don't at all disagree. I was even hesitant to use the hateful word because protocol is a bludgeon that has been used to abuse doctors and nurses and to dehumanize the delivery of healthcare. I've written a few cautionary tales about the dangers of checkbox fatigue and institutions that are more concerned with the appearance of quality rather than genuine quality, because the former is easier to measure. And, yet:

There are settings where checklists and protocols are essential. In a high stakes environment like the OR, with multiple stakeholding teams (anesthesia, nursing, surgery) interacting under resource limitations and other potential conflicts, a failure to coordinate efforts via pre-established plans will translate directly into patient harm. It is a setting where algorithms and standard operating procedures make sense, because they help contain the chaos and keep errors from slipping past unnoticed. Deviation from protocols in such settings may sometimes be necessary, but shouldn't be done lightly or without thought to the risks involved.

That said, I agree with all of your points, most especially #3. Which is extra true if there has been a task force or any other form of bureaucracy set up to ensure its enforcement. Once that happens, someone's job description begins to involve preserving that protocol, ensuring that it will always have someone to argue for its eternal necessity.