What type of error occurs when a nurse provides scissors instead of artery forceps (hemostatic forceps) to a doctor for cutting a vessel during surgery?

From the Guidelines

The nurse's action of giving the wrong instrument (scissors instead of artery forceps) to the doctor during surgery is a clear example of commission, as it involves doing something incorrectly or inappropriately, rather than failing to do something required. This error can be classified as negligence, which is a type of commission error where a healthcare provider fails to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation 1. The study on medication safety in the operating room highlights the significance of human error in hospitalized patients, causing an estimated 100,000 to 400,000 deaths in the USA annually, and notes that 70.3% of medication errors were deemed preventable 1.

In the context of the operating room, commission errors like the one described can have serious consequences, including patient harm and compromised surgical outcomes. The importance of clear communication, proper training, and attention to detail in the operating room environment cannot be overstated. The provision of incorrect instruments, such as scissors instead of artery forceps, is a fundamental breach of nursing responsibility and can lead to adverse events.

Key points to consider in this scenario include:

• The distinction between commission and omission errors, with commission errors involving taking an incorrect action and omission errors involving failing to take a necessary action
• The role of negligence in commission errors, where a healthcare provider fails to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation
• The importance of preventing human error in the operating room, given its significant contribution to patient harm and mortality 1
• The need for clear communication, proper training, and attention to detail in the operating room environment to prevent errors like the one described.

From the Research

Intraoperative Error

• The scenario described involves a nurse providing the wrong surgical instrument, scissors instead of artery forceps, to a doctor who intends to cut a vessel.
• This situation can be classified as a form of medical error, specifically an error of commission, which occurs when a healthcare provider takes an incorrect action or performs a wrong intervention 2.
• Commission errors, such as the one described, can lead to adverse outcomes, including patient harm or complications, and are a significant concern in healthcare settings.

Classification of Error

• The error in question can be categorized as a commission error, which involves doing something wrong, as opposed to an omission error, which involves failing to do something that should have been done.
• Commission errors, like giving the wrong instrument to the surgeon, are often the result of careless or negligent behavior and can have serious consequences for patient safety.

Relevance to Patient Safety

• The provided studies primarily focus on bleeding, infections, and antibiotic prophylaxis in surgical contexts, rather than specifically addressing errors like the one described 3, 4, 5, 6.
• However, these studies highlight the importance of careful management and attention to detail in surgical settings to prevent complications and ensure patient safety.
• While the studies do not directly address the scenario of providing wrong surgical instruments, they emphasize the need for vigilance and proper protocols to minimize risks and errors in healthcare.