Donna Penner - 44 year old female experiencing abdominal pain from an unknown origin and heavy bleeding during her period. Having exploratory surgery to investigate possible source of pain.

What do you think is going on with this patient?
(everyone to answer)

Initial Assessment ( ~3 min)

Surgeon notices that the patient is in distress and asks anesthesiologist what is wrong ...

nurse responds that the anesthesiologist is not present ...

Share what you are most concerned about.
(everyone to answer)

Review Assessment ( ~3 min)

Anesthesiologist returns ... injects patient ...

surgery continues
Summary:

Donna was awake but paralyzed during her exploratory surgery in 2008.

Donna felt every incision, every movement, but more terrifying, unable to let anyone know she was awake and feeling everything.
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
What systems do we have in place to prevent this?
(every team member to answer)
What system issues might have contributed to this outcome?
(every team member to answer)
Systems Discussion (~5 min)
Issues:
- recognition of conscious awareness
- staffing distraction
- patient advocacy
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