A Story Patient has known allergy to chlorhexidine. Patient was asleep and positioned ready for surgery. The team was waiting for the surgeon. No chlorhexidine had been used. The surgeon enters in a rush and he grabs chlorhexidine and begins to prep the patient himself. Everybody in the room knew that the patient had an allergy, except for the surgeon. Nobody says anything. Patient goes into anaphylaxis shock.
Why Don’t We Speak Up I’m afraid I’m embarrassed I’m stupid They will yell at me I might be wrong The surgeon is mean They won’t listen anyway It’s not that important
The Joint Commission has found that many times when sentinel events occur in the OR a member of the surgical team knew that the event was about to happen and they didn’t say anything.
Events That Have Happened Because Nobody Spoke Up Wrong Site Wrong Procedure Wrong Equipment Wrong/Missing Implant Wrong Medication/Allergy
The Solution Use special words that indicate that there is a problem. Both the sender and the receiver need to understand these words.