A fourth-year medical student on rotation in the pediatricintensive care unit (PICU) was invited to
observe the operative repair of a congenital heart lesion in thepediatric cardiac surgery operating room
(OR). When the student arrived in the OR, the patient was alreadyintubated and anesthetized, and
procedures were underway to prep the patient for surgery. Thestudent observed one of the team
members insert a Foley catheter into the female patient. He wassurprised to see that no efforts were
made to perform “sterile prep” before insertion. However, being newto this setting and assuming
different practices were used in pediatric patients, the studentdismissed the incident and did not
mention it to anyone in the OR.
The student followed the patient during her PICU course. On apostoperative day 3, the student found
that the patient had been febrile overnight and a urine culture hadgrown Pseudomonas aeruginosa. On
rounds, the student presented this new data, including the accountof the Foley placement in the OR.
The patient’s Foley catheter was discontinued and appropriateantibiotic coverage was provided.
Subsequent urine cultures were negative. After rounds, the studentwas approached by two attendings,
separately. One remarked that the information about the cathetershould not have been presented on
rounds due to concerns that patients and family members mightoverhear. The second attending told
the student this information should have been conveyed at the timeof the incident. Shortly thereafter,
the student submitted a report outlining the events in the OR tothe institutional patient safety office.
question
If you are the student in the OR, are you going to report theissue when you see it? If yes, why?
If no, why?
