What is the consequence of a nurse providing scissors instead of artery forceps to a doctor to cut a vessel in the intraoperative room?

Providing Scissors Instead of Artery Forceps in the Operating Room: A Commission Error

Providing scissors instead of artery forceps to a doctor for vessel cutting in the operating room is a commission error, as it represents an active mistake that could directly lead to patient harm through uncontrolled bleeding.

Understanding Medical Errors in the Operating Room

Medical errors in the operating room can be categorized as either commission or omission errors:

Commission Errors

Commission errors occur when an incorrect action is performed, such as:

• Providing the wrong instrument (scissors instead of artery forceps)
• Administering the wrong medication
• Performing the wrong procedure

In this specific case, providing scissors instead of artery forceps represents a commission error because:

1. It involves an active mistake (providing the wrong instrument)
2. It creates immediate risk of harm (potential uncontrolled bleeding)
3. It constitutes a deviation from standard operating room protocols

Omission Errors

Omission errors involve failing to perform necessary actions, such as:

• Forgetting to administer required medications
• Failing to monitor vital signs
• Not performing required safety checks

Consequences and Patient Safety Implications

The provision of scissors instead of artery forceps could lead to:

1. Increased risk of uncontrolled bleeding: Artery forceps are specifically designed to clamp vessels securely before cutting, while scissors are designed primarily for cutting 1.

2. Potential for serious morbidity or mortality: Uncontrolled bleeding in surgery is a major cause of adverse outcomes, including hemorrhagic shock and death.

3. Prolonged operative time: Additional time would be required to control bleeding that could have been prevented with proper instrumentation.

System Factors Contributing to Such Errors

The British Journal of Anaesthesia guidelines on medication safety in the operating room highlight principles that apply to all operating room errors, including instrument errors 1:

• Poor communication between team members
• Inadequate training or orientation of operating room personnel
• Failure to follow standardized procedures for instrument handling
• Fatigue or distraction among operating room staff
• Inadequate staffing or supervision

Prevention Strategies

To prevent such commission errors:

1. Standardized instrument verification: Implement a standardized process for verifying instruments before handing them to surgeons 1.

2. Clear communication protocols: Establish clear verbal communication protocols for requesting and confirming instruments 1.

3. Team training: Regular team training sessions focusing on communication and instrument handling 1.

4. Double-checking system: Implement a system where critical instruments are verbally confirmed before use 1.

5. Reporting culture: Foster a non-punitive reporting culture to encourage staff to report near-misses and errors 2.

Response to Error

When such an error occurs:

1. Immediate correction: The error should be immediately identified and corrected by providing the correct instrument.

2. Open disclosure: The error should be disclosed to the patient if it resulted in harm or required additional intervention 1.

3. Incident reporting: The event should be reported through appropriate channels for analysis and learning 2.

4. Systems approach: Focus on system improvements rather than individual blame 3.

Conclusion

The case described represents a clear commission error with potentially serious consequences for patient safety. Operating room teams should implement standardized processes for instrument handling and verification to prevent such errors, while maintaining a culture that encourages reporting and learning from mistakes rather than assigning blame.