Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.
PLoS One. 2024 Feb 26;19(2):e0298224. doi: 10.1371/journal.pone.0298224. eCollection 2024.
Charting is an essential component of professional nursing practice and is arguably a key element of patient safety in surgery: without proper, objective, and timely documentation, both benign and tragical errors can occur. From surgery on wrong patients to wrong limbs, to the omission of antibiotics administration, many harms can happen in the operating room. Documentation has thus served as a safeguard for patient safety, professional responsibility, and professional accountability. In this context, we were puzzled by the practices we observed with respect to charting compliance with the surgical safety checklist (SSC) during a study of surgical teams in a large, urban teaching hospital in Canada (pseudonym 'C&C').
This article leverages institutional ethnography and a subset of data from a larger study to describe and explain the social organisation of the system that monitored surgical safety compliance at C&C from the standpoint of operating room nurses. This data included fieldnotes from observations of 51 surgical cases, on-the-spot interviews with nurses, formal interviews with individuals who were involved in the design and implementation of the SSC, and open-ended questions from two rounds of survey of OR teams.
We found that the compliance form and not the SSC itself formed the basis for reporting. To meet hospital accuracy in charting goals and legislated compliance documentation reporting requirements nurses 'pre-charted' compliance with the surgical checklist. The adoption of this workaround technically violated nursing charting principles and put them in ethically untenable positions.
Documenting compliance of the SSC constituted a moral hazard, constrained nurses' autonomy and moral agency, and obscured poor checklist adherence. The findings highlight how local and extra local texts, technologies and relations create ethical issues, raise questions about the effectiveness of resulting data for decision-making and contribute to ongoing conversations about nursing workarounds.
图表记录是专业护理实践的重要组成部分，可以说是手术患者安全的关键要素：如果没有适当、客观和及时的记录，就可能会发生良性和悲剧性的错误。从为错误的患者进行手术到错误的肢体，再到抗生素使用的遗漏，手术室中可能会发生许多危害。因此，记录为患者安全、专业责任和专业问责制提供了保障。在对加拿大一家大型城市教学医院的手术团队进行研究时，我们对图表记录与手术安全检查表（SSC）的一致性观察到的做法感到困惑（化名“C&C”）。
本文利用机构民族志和更大研究的一部分数据，从手术室护士的角度描述和解释了监测 C&C 手术安全合规性的系统的社会组织。这些数据包括对 51 例手术案例的现场观察记录、对护士的现场访谈、对参与 SSC 设计和实施的个人的正式访谈，以及手术室团队两轮开放式问题调查的结果。
我们发现，合规表格而不是 SSC 本身构成了报告的基础。为了满足医院对图表记录准确性和法规合规性文件报告要求，护士们“预先记录”了手术检查表的合规性。这种解决方法的采用在技术上违反了护理图表记录原则，使他们处于道德上不可接受的境地。
记录 SSC 的合规性构成了道德风险，限制了护士的自主权和道德代理，并掩盖了较差的检查表遵守情况。研究结果强调了本地和外部文本、技术和关系如何产生道德问题，对决策产生的数据的有效性提出了质疑，并为护理权宜之计的持续讨论做出了贡献。
