A RISK MANAGEMENT PROFESSIONAL must look beyond the generally obvious.
In the case described in the FierceHealthcare article 3 ways to guard against distracted doctoring even as digital devices add to the problem1 a “patient safety risk manager at physician-owned medical malpractice insurer “missed the point.
THE SUBJECT was electronic media in the surgery suite, specifically “smart” devices.
According to patient safety risk manager Ms. Shelley Rizzo, non-medically necessary “smart” devices are a risk in the OR. The article cited several occasions when such devices endangered patients’ lives.
Other than the fact Ms. Rizzo is employed by an insurance company that sells policies to doctors, the article fails to list any risk management credentials (often useless in any case) nor does it present any information regarding risk management experience. The foregoing may explain why Ms. Rizzo failed to recommend what, to this scrivener, the most obvious action to take.
What she recommended
Ms. Rizzo said there are ways doctors and practices can protect themselves.
- Have policies in place. For instance, a policy may say it is okay for doctors or medical professionals to use the internet to look up a medical protocol, but not for personal reasons such as checking Facebook. It might also address the issue of taking and circulating photos via cell phones, a reality that became well known in the death of comedian Joan Rivers. An investigation found that one of the doctors took a photo of Rivers during a throat procedure that led to her death.
- Provide mandatory education to staff. Organizations should provide ongoing staff training about the dangers distracted medical professionals can create. Staff should know when it is inappropriate to use digital devices. Doctors and others can take commonsense steps such as silencing the ringtone on their phone to avoid distractions.
What she FAILED to recommend
The obvious recommendation should have been
BAN NON-MEDICALLY NECESSARY ELECTRONICS FROM THE OR
Simple.
Human nature is to use electronic media without giving the time or location a second thought.
How many times have you been in a “No phones” zone and heard phone conversations? How many times have you seen signs reading “Please mute cell phones” and the heard phones ringing?
Answering a cell phone’s ring or a smart phone’s incoming text message “ping” is automatic for most people who use these devices. A non-thinking response.
The problem is, a distraction in the OR (or ER, or for that matter during ANY critical action) can endanger someone’s life.
If states and municipalities ban use of cell phones when driving, obviously electronic toys are a problem.
If a surgeon is in the middle of an operation and needs to consult with another doctor in another location (the surgeon probably shouldn’t be cutting in the first place*) for step-by-step instructions, then electronic media is medically necessary.
- * There are times when such communication is necessary, but for non-emergency surgery, those times are exceedingly rare.
How Ms. Rizzo could ignore the most basic recommendation is beyond my ken. Her employer writes insurance policies for physicians so I would guess avoiding law suits is desirable. (Even of her company prevails, it still has legal fees to pay.)
The best, the only way, to avoid law suits claiming someone in the OR was “distracted” by a cell phone or other electronic device is BAN THEM FROM THE SURGERY SUITE and every other area where interruptions can be dangerous for the patients (e.g., emergency rooms).
As to Ms. Rizzo’s recommendations:
- Have policies in place Policies are of no value unless they are read by all and enforced. Ms. Rizzo’s policy fails to address the primary issue: distractions during patient procedures.
Provide mandatory education to staff. Having tried “mandatory education” – even coupled with policies and procedures – to prevent people from opening emails from unknown sources and from giving out confidential information over the phone, I know first hand that too often the education goes in one ear and out the other,
Insurance companies usually are pretty good at recommending protections for their clients and the insurer. In this case, the insurer’s risk manager completely missed the boat.
Elsewhere on the web
- Do Cell Phones Belong In The Operating Room?2
Woman sues surgeon, claims he was on cell phone during operation 3
Smartphone Photos in OR Not So Smart, Says Privacy Expert 4
Concerns about usage of smartphones in operating room and critical care scenario 5
Should Cell Phones Be Allowed During Surgery? 6
Sources
1. http://tinyurl.com/yacma5x8
2. http://tinyurl.com/y8g5lnm4
3. http://tinyurl.com/ycjhtqxs
4. https://www.medscape.com/viewarticle/886041
5. http://tinyurl.com/y7wdndpz
6. http://tinyurl.com/y9cro2dc
PLAGIARISM is the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.
No comments:
Post a Comment