MOTHER HEN Is patient safety really being compromised or are we sometimes guilty of overreacting?

An aware OR team member calling to mind an important drug allergy or skin lesion? That's good for patient safety. An overzealous OR team member conveying alarm over something that, in reality, has no clinical consequence? That's unreasonable. Don't let one dissenting voice in the OR team halt an excursion to the OR. Here, responsive leadership is necessary to protect the patient's best interests. Some examples:

• Body piercing. Just what are the risks of performing surgery on a patient with a body piercing? It appears to be a nebulous zone. Some well-intentioned staff will roadblock any surgery involving the use of electrocautery when any body piercing is present. Take the young woman who recently presented to our outpatient facility for a hip arthroscopy. Her nose ring was firmly implanted in a nostril and not readily removable. A vocal team member refused to allow the surgery despite the anesthesia attending's consent. Not aware of any immediate harm to the patient, I agreed that surgery should proceed.

But the team member was obstinate and insisted on the ring removal. Several minutes of unusual pain and patient suffering later, the ring was eventually removed, albeit with great difficulty.

What was the best action for the patient? Who is to assume leadership? Effective leadership would not allow undue pain and suffering when no realistic threat is present. Conversely, when there is a real threat, it needs to be conveyed to all team members.

• Consent. Informed consent is an essential element of providing responsible care to patients and protects them from overt unseen, aggressive surgical insults. As a shoulder surgeon, I am careful to include 'surgical arthroscopy' in my consent with the intent of including possible procedures that may ensue during the course of a surgical arthroscopic procedure, such as debridement, chondroplasty and bone spur contouring. The conversations I have with my patients pre-operatively explain the likely and not-so-likely findings possible during surgery and the expected course of action.

Some team members dissent when they perceive surgical treatment exceeds the purview of the consent. Thankfully, such a well-intentioned approach will prevent an irresponsible surgeon from making large open incisions when the consent read 'arthroscopy.'

However, should there be an issue at stake when the surgeon elects to remove a loose body, not seen on imaging, when the terms 'loose body excision' are not listed on the surgical consent? Similarly, if the surgeon encounters an incidental small rotator cuff tear, again, not seen on pre-operative scans, should it be repaired even though 'cuff repair' is not expressly listed on the consent? Is it better to forgo treatment if concerns exist about disclosure and risk another anesthesia?

Where does the buck stop?
These questions need to be resolved and there does ultimately have to be a chain of command with explicit leadership. Where does the buck stop? Improving patient safety and communication amongst the healthcare team is an honorable initiative, but leadership is about doing the right thing at the right time for the right reason. It is not about ego or self-gain. In truth, we all need to do a better job of communicating to each other what is truly best for the patient. OSM