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  • A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse

    • UK
    • Accounts and narratives
    • New
    • Patients and public, Health and care staff, Patient safety leads, Researchers/academics

    Summary

    What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did! 

    Content

    I was once working in a private operating theatre where, to my horror, the surgeon accidentally dropped an instrument on the floor, picked it up and reused it without it going through a steriliser. In my 30 years of working as a theatre nurse, I had never seen anything like this. I felt sick to my stomach! Is this what happens in private hospitals?

    I reported it immediately to the senior staff on duty and also the theatre manager. I also sent through a report at the end of the case. Nothing happened, except my shifts were blocked for reporting the incident . 

    I no longer work in that hospital. I feel hurt. My mental health has also suffered as I feel tortured.

    I question myself. Did I do the right thing by reporting it? Because now I do not have a job and I am using my savings to survive.

    If I was a permanent member of staff, I would still be working. Is this why staff do not report incidents? For fear of losing their jobs?

    What about the safety of the patient?

    I tried calling to speak to anyone who would listen. I did not have any luck – I found all avenues were blocked. There was no Speak Up Guardians in post.

    I feel I did the right thing by reporting it, but I was not supported by management. Where is the system in private hospitals to protect locum theatre staff? Why is this allowed to go on? In theatres, we are the patient's advocate. We are only there to ensure the patient is safe at all times.

    Would I do things differently if it happens again, now that I know the consequences?

    Yes! Absolutely 100%.

    I will continue to speak up and send through a report.

    What will you do?

    About the Author

    Theatre scrub nurse, private hospital.

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    10 Comments

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    Thank you for sharing such a candid account at what must be a very difficult time.

    If you have a story to tell, please do share it with us on the hub. By sharing our experiences, we can start having honest conversations around these topics.

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    'Absolutely 100%' - I so admire you for doing the right thing in reporting and having the integrity, compassion and commitment to patient safety to do so again. As the Chief Executive of Patient Safety Learning, wife, daughter and mother, thank you. I hope the support you receive in telling your story will help with the distress and anguish this incident has caused you. Thank you for sharing 

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    I applaud the integrity of the Originator of this thread for highlighting the iniquity in our healthcare sector, where a private institution performing procedures often on behalf of the NHS is not required to provide a platform that enables and encourages staff witnessing misconduct or improper behaviour to speak-up. It does seem a little odd that while NHS establishments are required as part of their mandate to have a "Freedom To Speak Up Guardian" system, private healthcare providers do not.

    I am aware that there is an alternative, commercial, system that provides staff with a safe platform for raising issues, and a number of social-care organisations and NHS Trusts are presently benefiting from the pseudo-anonymised firewall that is a security feature, enabling dialogue without the possibility of compromised personal security and the fear of retribution such as we see in this case. This platform is currently under consideration by a number of CCG, and has been presented to STP and HSCP in the UK and similar organisations abroad.

     

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    Thank you for the comment @Andrew Ottaway   I saw that the FTSU guardian commented on twitter that the private sector have to have a FTSU guardian if they are  providing NHS care (in this case I don't think they are)  So what happens here?  

    I expect people using private healthcare do not realise how unsafe their care could be.  They are paying the price - literally.   Terrifying

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    Hi @Claire Cox I agree that it does appear that there's a significant loophole in patient safety, and I find it odd that while the CQC can and indeed do make comment in their inspection reports regarding staff-engagement - sometimes quite critical comment - there seems to be no indication that a system similar to FTSUG is demanded of private healthcare establishments in the same way that they do of NHS Trusts. I hope that this is an oversight to be addressed, and not an indication that FTSUG is seen as a panacea for public consumption.

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    Hi @Andrew Ottaway and @Claire Cox

    Thanks for the discussion and update Andrew. I think it would be helpful to clarify responsibilities and I will write next week to the FTSUG's office, the CQC and NHSI.  It does appear to be a loophole.

    Will keep everyone posted.

    Helen

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    Does also show the contractual vulnerabilities of bank and locum staff in raising issues. Staff shouldn't have to chose between doing the right thing, their professional responsibilities and their livelihood. I'll write to the GMC, NMC and HCPC on this issue. 

    Thanks again to the brave reporter.

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    Thank you for sharing with us the incident which is clearly something that will harm a patient. Firstly you should be congratulated in speaking up while others stood back and said nothing.  Stand firm in your beliefs that you have done the right thing and do not let anyone tell you otherwise. With regard to the FTSPUG service, I used the service at my current hospital after an unauthorised visitor made their way into an operating theatre. While I challenged what the person was doing in the operating theatre everyone including senior management looked the other way. After contacting the FTSUG service they took my complaint seriously and presented it to the board of Directors on my behalf.

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    Edited by Aston02 grammer

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    That's great to hear @Aston02. Disappointing that you had to use the service but shows why it's needed. Shocked that senior management behaved that way. Was there any follow up with them do you know?

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