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STUDENT BLOG

'I made a mistake in surgery; it was vital to change my practice'

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I was scrubbed in assisting a surgeon who was doing a wedge resection, potentially leading to a lobectomy.

The surgeon was using Roberts forceps with a pair of straight Kelly forceps and mounted peanuts to manipulate the lung tissue. The aim was to separate the tissue from the vessels in preparation for the lobectomy to take place.

Although I know the difference between the instruments, the surgeon was very fast, and as I was new to scrubbing in at times I had difficulty keeping up with the speed at which specific instruments were being requested.

In one incident I passed the surgeon some scissors instead of forceps, which my mentor did highlight to the surgeon after he checked the instrument.

”After the procedure my mentor and I discussed the incident”

After the procedure my mentor and I discussed the incident. She asked me about the potential dangers of this action, especially if the surgeon was not aware and did not check the instrument prior to their use. I explained and agreed about the potential implications of this action, in relation to the thoracic area.

I further apologised for the incident and thanked her for being there to support me. It is important to note that the patient was not harmed and no negative actions occurred as a consequence of my mistake.

”I spoke to each person I scrubbed in with, informed them of my mistake and adapted my practice”

However, it was highlighted to me there is the potential for future reoccurrence.

By reflecting on my practice and mistake, as well as being honest and reflective in my actions, I modified my practice and the way I set up when scrubbed in and assisting at the operating table.

I spoke to each person I scrubbed in with, informed them of my mistake and adapted my practice with them for consistency.

I now put the tissue scissors and suture scissors at the end nearest to me on the mayo stand with another pair under the kidney dish that contains the mounted blade.

The Roberts are separated by the debakey forceps and include two mounted peanuts and one without. I further state what I am passing the surgeon for additional peace of mind both for me and the person I scrub with.

”Since this incident I am extremely diligent about the location of all instruments”

Since this incident I am extremely diligent about the location of all instruments. This includes the position of equipment on mayo stands as well as the table. Further considerations may seem basic to experienced staff but they enabled me to practise replacing where I was due to take instruments from and develop my own way of setting up.

The ability to locate specific instruments that a surgeon may ask for or take from the quiver is important from a pre- and post-operative check and patient safety perspective and is useful in cases of an emergency.

This is an example of how reflection can be useful to practice by preventing the occurence of potentially dangerous incidents.

Laura Hodgetts is a current student nurse

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