An incident involving an out-of-control OR team illustrates how undignified and abusive behavior can occur even at facilities with high standards.
R. Stephen Trosty, JD, MHA, ARM, CPHRM, president of Risk Management Consulting in Haslett, MI, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago, was a risk manager at a hospital when he learned of the incident.
A patient was about to undergo surgery, and when the OR staff undraped him, the man was found to have an extremely large penis and scrotum.
“Not only was this mentioned and laughed about by the people in the room, but other hospital personnel were invited to come into the operating room to witness this. It was referred to as a ‘true gift of nature,’” Trosty recalls. “All sorts of comments were made about how fortunate his wife was and how talented he must be.”
When Trosty learned of the incident from staff members who were bothered by it, he conducted an investigation to determine exactly what happened. Then he went to the chief of staff, the head of the department, the vice president of nursing, and the CEO to insist that it be dealt with immediately and effectively.
“Disciplinary action was taken at all levels, up to and including the firing of non-physician staff. The physician who was most responsible had his privileges revoked,” Trosty says. “I am not sure that this actually permanently stopped the behavior, but I do believe it was a major deterrent to it happening again. All levels of the institution gave the message that this type of behavior would not be tolerated, and it was explicitly stated that anyone who participated in this type of behavior in the future faced equally serious consequences.”
The incident was used as a teaching example for staff and physicians thereafter.
