Where’s the Baby?
Posted by jdtaylor on September 9, 2013
I was in an ENT room and things were heading smoothly. We were ahead of schedule and everyone was happy. The room turned over in fifteen minutes flat and I went to check on the next patient. The next patient due in my OR suite was having the very simple procedure of getting her ears cleaned of excess wax. The reason that it was being done in the operating room was because she was severely developmentally delayed. She was pleasant enough and her caregiver was at the bedside to assist. To decrease some of the anxiety, the patient was allowed to keep her favorite blanket along with a well worn baby doll wrapped in that blanket. We made it through the check in process and got an IV started and was ready to go. The anesthesia team had done their part with a pre-op dose of Versed we were off. Another twenty minutes of getting positioned and off to sleep. I took the doll and the blanket and put it under the transport stretcher so it wouldn’t be lost. The procedure was finally underway. This is when my lunch relief came in. When we have shift change, give a break, or leave for any reason, we have this check list, just like the check list airline pilots use when they get ready to take off. This is what we use to prevent errors and save lives. This check list is called our “S-Bar.” Well, I gave the report to the relief nurse and then I departed. I had my “Budget Gourmet” and returned to my room. On the way back, my nurse manager cornered me saying that “needed to have a word.” In the last month, we have had our nurse manager retire and hire a new manager. She is still learning the ropes of our peculiar department. I have been there for several years, I am the shop steward, as well as the service lead for two surgical services. In the beginning, I offered to “give any assistance possible to ease the transition.” She has asked for payment on that promise several times. the process, We had our chat as we walked slowly through the OR. About the time we passed the front desk, the nurse in my room called for turnover. The I saw her coming down the hallway following the anesthesia team pushing the bed with her patient. They were headed to the recovery room where the nurse would give the S-Bar report to the recovery team. As they went by, I asked, “well, how did it go?” The nurse looked at me a with a pained expression, “in your report, you didn’t tell me about the baby!…”
My nurse manager was perplexed and looked at me, “uh, what baby… what does she mean baby?”
The other nurse not letting up, “That was a terrible omission… why didn’t you tell me about the baby?”
Looking at my manager and back at the other nurse, “I’m sorry, I didn’t think to include the stupid baby… it was under the stretcher. I left it under the stretcher.
My nurse manager, “you did what with the baby?”
Seeing that she was getting more upset, I said, “It’s a long story, don’t worry, it was a plastic baby that, apparently the patient felt was very important… I’m sorry about the confusion.”
It just goes to show you, even when you have a fancy checklist, sometimes things just get missed… even babies.