Monday Med Mania

Time Out Procedure

I consulted on a case that rested solely on the "Time Out" procedure used in the operating room. All the documentation was neatly in order, yet somehow the patient ended up having the wrong part removed. Finally, inconsistent stories emerged as each inidividual member of the surgical team was deposed. The deviations in standards of care surrounding the "Time Out" procedure were clearly identified:

• The operating was noisy during the "Time Out"
• The attending physician was not even present when the "Time Out" took place
• A right-left distinction was never identified during the "Time Out"

Surgical team members must remeber that the "Time Out" procedure was put in place for a reason. We don't do "Time Out" just to satisfy Joint Commission requirements - We do it to protect the patient. The attending physician has to be present, and the "Time Out" must take place just prior to the surgery in a quiet room. A right-left distinction must be clearly identified, and if the surgery requires more than one procedure, a new "Time Out" must be done before each individual procedure. This process eliminates the risk of wrong site, wrong procedure or wrong person surgery.

I came across one facility's Universal Protocol on the internet for "Time Out" procedure which identifies the process that must be followed: Universal Protocol - Time Out. This may help those that need clarification with the process. There are also some helpful videos on YouTube that actually simulate the process as well. For more information on "Time Out" Procedures or other Universal Protocols you may email us at mcook@cook-legalnursing.com.

Monday Med Mania

Pain Assessment Doesn't End with Pain Scale

As a legal nurse consultant I review massive amounts of medical records. Part of that review includes pain assessments of which I can say without hesitation hardly ever provide a sufficient description of patient pain. I'm sure all nurses understand that pain scale was integrated into nursing documentation to help standardize an important part of pain assessment; however, many nurses still do not grasp the concept that pain assessment does not end with pain scale.

I review many medical records that will note a pain scale above zero describing pain intensity and/or severity which then leaves me hanging with many questions regarding a more descriptive evaluation of pain:

• Where is the pain?


• When did the pain start?


• Is this pain the same as previous pain or something new?


• Is the pain constant or intermittent?


• How long does the pain last?


• How long is the absence of pain?


• What type of pain is it? Burning, Stabbing, Dull, Cramping, Pulling, Tearing, Throbbing, Tingling, Aching, etc.?


• Is the pain deep or superficial?


• Can the patient describe if the pain feels like it originates from bone, muscle, organs or skin?


• Does the pain radiate or is it isolated to one specific area?


• What relieves the pain?


• What exacerbates the pain?


• Is the pain associated with anything specific? Food, Activity, Exposure, etc.?


• Are there any associated symptoms with the pain?


• What are the nonverbal signs? Facial Expressions, Crying, Body Movements, Guarding, Position, etc.?


• What are the paitient's current vital signs?

If all these questions can be answered within a pain assessment then there is sufficient documentation regarding patient pain. Even when patients are admitted for pain, a nurse must never assume the paitient's complaint of pain is derived from the same origin as the presenting complaint. An adequate pain assessment is required routinely to determine if the pain is the same or something new, and that can not be determined with a pain scale alone.

Monday Med Mania

Coordination of Response to Obstetrical Emergencies

Since my area of specialty is high risk obstetrics, I spend a lot of time reviewing and analyzing medical records relative to obstetrical malpractice cases. As an obstetrical nurse for almost twenty years it really gives me a lot of grief when I review medical records to realize coordination of response to obstetrical emergencies has been mismanged to the point of malpractice. This seems to be a constant within almost every malpractice case I review.

The major elements that fall within this issue include:

• Failure to anticipate and prepare
• Failure to commuicate
• Failure to fully understand responsbilities

Obstetrical nurses must understand that the possibility of obstetrical emergencies can occur at any time, especially when high risk patients and/or use of induction agents are involved. A poorly coordinated response results in panic and chaos ultimately creating a situation that places both mother and baby in danger. A poor outcome is then directly contributed to events that were both avoidable and incompetent.

The use of emergency simulation drills on obstetrical units does help to better prepare for obstetrical emergencies; however, all staff including physicians must be on board to effectively coordinate the response. On the other hand, if the obstetrical staff fails to acknowledge the reality of a high risk situation, then simulation drills are rendered useless.

For coordination of response in obstetrical emergencies to be effective there are four seperate and distinct factors that must take place:

• Anticipation
• Preparation
• Communication
• Delegation

These are the four factors I identify within medical records of an obstetrical malpractice case. I really hate to say it, but most of the cases I am asked to consult for will reveal a breakdown in one or more of these four areas. With the number of obstetrical law suits escalating, it is imperative that obstetrical nursing supervisors properly educate their staff the significance of obstetrical emergency response.

For more information on this subject matter and obstetrical staff education, contact Marinna Cook, RN, CLNC at mcook@cook-legalnursing.com or call (661) 368-2290.