Medical Errors, Passing Along Nursing Knowledge, and Stress and Burnout: Three Books

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Excerpt

The three books reviewed are quite different from each other. The first book is a first-person report of medical errors and their sequelae. The second book focuses on knowledge transfer as part of succession planning, and the third book discusses stress and burnout.
The first book is Anatomy of Medical Errors: The Patient in Room 2 by Donna Helen Crisp. It is 200 pages in length, published by Sigma Theta Tau International in 2016, and costs U.S. $29.95. It has a foreword and a prologue, 23 chapters, an epilogue, a glossary, a readers' guide, and references. Crisp has varied background including becoming a nurse after degrees in social work, law, and music. She uses quotes from Shakespeare, a master of tragedy, to help her tell her story.
I could not decide whether to review this book and thus bring it to your attention because I found it to be disturbing. I think the author wants the book to be disturbing, as she tells her story of surviving preventable errors and subsequently trying to learn what happened and who was accountable for the errors. From this perspective, Crisp accomplished her goal.
Crisp was diagnosed with uterine endometrial cancer and underwent surgery that resulted in intestinal tears. She details how in her surgeon's absence she did not receive adequate postoperative care and her torn bowel was not diagnosed in a timely manner. The residents overseeing her care did not act on her report of unrelenting abdominal pain, nor the changes in her vital signs resulting from the pain until approximately 18 hours postoperatively. At this time, a computed tomographic (CT) scan was ordered but not completed for another 12 hours. The CT scan showed “free intraperitoneal spill of oral contrast material concerning for bowel perforation.” Two hours later, Crisp underwent a second surgery to repair her bowel.
However, it took ½ hour after the surgery began for the surgeons to realize that, as stated by Crisp, “the student nurse anesthetist had botched the intubation by performing the wrong technique” (p. 26) that resulted in Crisp aspirating CT dye. As a result, she developed respiratory acidosis and going into shock. Further complications occurred, and she underwent four more surgeries, leaving her with a 4 × 6-in. hole in the middle of her belly with her abdominal muscles retracted to each side. Her abdominal infection had “eaten away” her skin, so the hole was not closed. She had a wound vacuum pump 24 hours a day for more than 2 months due to the concern that the infection may continue and the wound needed to heal from the inside out. At various times during her stay in the surgical intensive care unit, she was in a coma, on a ventilator, had tubes from all orifices, and numerous intravenous catheters. She also suffered from psychosis. During all of this, she did not feel she had an advocate for her, except for her sisters, who were marginalized by the physicians.
Crisp repeatedly reports that she did not get clear and useful answers from the physicians. This indictment continues through to the end of the book. Unfortunately, except for a few notable exceptions, the nurses caring for her also seemed not to have served as an advocate for her or, more importantly to Crisp, seen her as a person, not the “patient in Room 2.”
Reading about Crisp's experience was gut-wrenching. I just kept waiting for someone, a nurse, to step in and serve as her advocate and recognize her as a person and as a fellow nurse.
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