to stand up for what you think is right."
But not everyone follows her example. Some
staff members just don't feel comfortable
doing so, because of the OR's traditional sur-
geon-first hierarchy, or perhaps they fear retri-
bution or maybe they simply haven't been
empowered to intervene. It's an especially
tough situation for junior nurses, says Cmdr.
Julie Conrardy, MSN, RN, CNS-BC, CNS-CP,
CNOR, the U.S. Navy's director of the periop-
erative nurse training program, East Coast.
"But as the patient's advocate in the OR, it's
your responsibility to act as the safety net,"
she says. "Everyone in the OR has to have the
confidence to speak up like Jessica did, and
that has to start outside of the OR."
Although the above scenario might have
ended fine even if Lt. Naranjo hadn't spoken
up, the what-if question it raises should send a
chill down every facility leader's spine. Her
experience — multiple procedures being per-
formed on a patient without a proper second
time out — is a textbook example of a situa-
tion that could have resulted in an avoidable
error capable of causing irreparable patient
harm. And it often does.
From 2005 to 2016, The Joint Commission
reviewed 9,945 sentinel events, including 1,281
wrong-site surgeries — which encapsulates
wrong-patient, wrong-procedure and wrong-
5 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A U G U S T 2 0 1 7
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