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Medical Error Contributes to Ethical Predicament

Heather Durkin

James Madison University


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Medical Error Contributes to Ethical Predicament

Introduction

Sterility is an important aspect of healthcare and should be followed precisely and strictly

when needed in order to prevent contamination and infection. Breaking sterility in any sterile

protocol is an example of a medial error. According to Tacconelli, “Sterile procedures are

defined as those in which the surgical site is free from infection and inflammation and in which

neither the respiratory nor the gastrointestinal nor the urinary tract are opened” (2016). Many

countries have introduced requirements to decrease the rate of infection from sterile procedures.

Germany in particular has a goal of complete sterility and has stated, “A national campaign for

the creation of targeting zero health-care associated infections and zero tolerance for unsafe

practices is long overdue” (Below 2010). Although it is nearly impossible to perform a

completely sterile procedure with a rate of zero due to microorganisms in the air and other

factors, I believe that people should try their best to work with this mindset during sterile

procedures to avoid infections. According to the German Medical Science Publishing House,

“The harvesting of bone marrow is performed under aseptic conditions comparable to those

during a surgical puncture” (2010). The procedure I examined where sterility was broken and a

medical error occurred was during a bone marrow biopsy.

Background

During one of clinical experiences, I was faced with an ethically difficulty situation. I

observed a medical error while attending a procedure where a physician was performing a bone

marrow biopsy on a patient’s iliac crest. As this was a sterile procedure, I paid close attention to

contamination risk. The physician washed his hands, set up the aspiration kit on the bedside table

and put on his sterile gloves. During the procedure, I noticed that the physician had turned his
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back to the sterile field because the table was positioned behind him. I knew this was wrong but I

did not say anything because I did not want to cause a distraction during the procedure and I was

afraid to confront the physician. A more ethical reaction would have been to notify the physician

that the sterile field was broken. This situation caused me moral distress. Moral distress occurs

when one knows the right action to take but feel restrained to do so. I knew that the physician

was not performing the procedure in a sterile manner, but I was afraid to confront the physician

because at the time I felt powerless as a nursing student. There were also two other nurses in the

room during the procedure so I felt that it was not my place to tell the physician what he was

doing wrong. I knew that he was more trained than I was and that he might get upset. If I could

go back to this situation, I would have made the ethically correct action and I would have

politely informed the physician that the sterile field had been broken and made sure that he used

another kit.

Methods/ Findings

To analyze this situation I am using the James Madison University Eight Key Questions.

The questions are provided as a source to guide in the decision making process. The eight

principles of fairness, outcomes, responsibilities, character, liberty, empathy, authority and rights

all aid in making an ethical decision. They challenge you to weigh the risks and benefits to make

the most fair and correct decision (Madison Collaborative).

The Eight Key Questions can apply to the situation that I encountered in clinical and by

using this tool I can answer each of the key questions based on the most ethical actions that I

would consider. When considering fairness, I would have had to be reasonable to both the patient

and the doctor. It would be fair for the patient to know that doctor was not using a sterile

technique and fair to the doctor to tell him that so that he does not repeat this error in the future.
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When looking at outcomes, I could have notified the doctor about his wrongdoing, which could

have prevented an infection for the patient. As far as responsibilities, it was the doctor’s

responsibility to carry out procedure safely and it was also my responsibility to notify the doctor

that he turned his back to the sterile field.

Character defines what action best reflects who I am and the person I want to become. As

a nurse, I want to ensure that safety is always being followed. To guarantee this, I have to

confirm that others are also following the aspects of safety to prevent patient harm. It is

important to ensure that the patient is safe while receiving the biopsy. Liberty involves freedom

and personal autonomy. I had the freedom to speak up and the patient’s autonomy would have

allowed the patient to decide whether or not she wanted to continue. Speaking to the doctor and

allowing the patient to make a decision are two actions that I should have taken. For empathy,

one should consider how they would act if a loved one was in the situation. If I was present and

this procedure was on one of my family members, I would make sure that everything was done

correctly and that high safety standards were observed. Authority is a big deal in health care

because according to the law and principles of the health care institution, you are expected to be

safe and act in the patient’s best interest. In this situation, the health institution expects the doctor

to perform the procedure carefully and safely and as a nursing student, I am expected to ensure

patient safety and collaborate with the health care team. When analyzing the topic of rights, it

was the patient’s right to know that the doctor was not following sterility and the doctor’s right

to know that he made a medical error. These Eight Key Questions act as a framework that can

guide anyone in the decision making process by highlighting very important values.

Another tool that can be used to guide one’s actions to create an ethical decision is the

American Nurses Association code of ethics. One provision listed in the code of ethics that I felt
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applied to the ethical situation was provision eight, which states, “The nurse collaborates with

other health professionals and public to protect human rights, promote health diplomacy, and

reduce health disparities” (2009). The provision explains that every human being has the right to

the highest attainable standard of health and I believe that the patient in my situation had the

right to the safest possible procedure. The provision also states that the nurses must bring

attention to human rights violations in all settings and that collaborating with the healthcare team

is essential. I think that it is vital that there is effective communication and collaboration between

the members of a healthcare team. In this particular scenario, I think it is important that there was

collaboration with the doctor about following safety and making sure no patient’s rights are

violated. The ANA code of ethics helps to direct nurses in their actions to ensure that the most

ethical decision is being made.

Conclusion

From this experience, I have learned that the correct course of action is to speak up and

not be afraid of the consequences. It is important to act in the safest manner for both the patient

and oneself. Breaking sterility is an example of a medical error, one of the most severe risks to a

patient. The most important goal of modern hospital hygiene and infection control is to give

patients the best possible protection against avoidable hospital acquired infections (Tacconelli

2016). I believe this to be true and after following the Eight Key Questions and ANA code of

ethics, I know that if I were ever faced with this situation again, I would immediately speak up to

the doctor. I want to be sure that any kind of hospital acquired infection, or any risks that puts the

patient in danger is avoided. Overall, I believe that this situation was a learning experience and I

now will be able to use these tools to make correct ethical decisions and support patient’s rights

to safety and prevent medical errors from occurring.


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References

Below, H., Ryll, S., Empen, K., Dornquast, T., Felix, S., Rosenau, H., & ... Kramer, A. (2010).

Impact of surface disinfection and sterile draping of furniture on room air quality in a

cardiac procedure room with a ventilation and air-conditioning system (extrusion airflow,

cleanroom class 1b (DIN 1946-4)). GMS Krankenhaushygiene Interdisziplinaer, 5(1), 1-

16. doi:10.3205/dgkh000153

James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in

action. Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml

National Student Nurses’ Association, Inc. (2009). Code of Ethics: Part II, Code of academic

and clinical conduct and interpretative statements. Available from http://www.nsna.org

Tacconelli, E., Müller, N. F., Lemmen, S., Mutters, N. T., Hagel, S., & Meyer, E. (2016).

Infection Risk in Sterile Operative Procedures. Deutsches Aerzteblatt International,

113(16), 271-278. doi:10.3238/arztebl.2016.0271