Reflective Assignment On an Incident the Happened In an Operating Theatre - Essay Example

Reflective assignment on an incident the happened in an operating theatre Health sciences and medicine Introduction Reflection is an important attribute in any professional since it gives an individual an avenue to evaluate an incident that happened more calmly and come up with recommendations if any. It enables a health professional to be better prepared to handle such an incident in the future and not to repeat the same mistakes in case the incident resulted from undue negligence. This reflective paper will us Gibbs reflective cycle (1998), to reflect an incident that happened in the operating theatre last year 01/01/2010. In concurrence with the reflection, this paper will also identify and evaluate the relevant legislation and guidance, identify and evaluate the professional and legal considerations, and identify and evaluate communication issues. Recommendations will be developed and the discussion and appraisal of current research relating to the issues outlined. Body Gibbs reflective cycle outlines description as the first stage in reflection. It was on 01/01/2010 during a dental surgery that my colleague had requested me to stand in for her as she went to take her lunch break. The chief anesthesiologist requested his assistant to administer a reversal that was aimed at enabling the patient to be able to breathe simultaneously and hence extubation from mechanical support. Upon administration of the drug, the patient did not commence simultaneous breathing and that when my eyes caught the attention of an open muscle relaxant ampoule. I enquired from the assistant if that was the drug he had given and he admitted that he had administered the wrong drug since he had not bothered to read the two ampoules present. Luckily, the patient did not encounter any harm but the patient delayed in being extubated and had an unduly long recovery process (Health Professional Council 2008: 1). Illustration of feelings is the second stage in reflection. I experienced anxiety when I discovered that the patient had not yet regained spontaneous breathing following administration of the reversal agent yet it should occur immediately. This filled me with doubt and a feeling of apprehension filled me when I discovered that there were two empty ampoules on the drug trolley. “Could have the assistant given the wrong drug?” intense feeling I had as I reached out for the ampoule that had been administered and it dawned on me that the assistant had administered a muscle relaxant depressing the respiration system even more. I have a feeling of relief when it was asserted that the patient had not encountered any harm although he took long to be extubated impairing his recovery (Health Professional Council 2008: 1). Gibbs reflective cycle outlines evaluation as the third stage in the cycle of reflection. From my evaluation, the good thing that happened in the incident is my being there at the right time. My alertness enabled me to discover that the patient had taken ling to recover and that there were two empty ampoules on the drug trolley. It was also a relief when I informed the assistant that he had administered a wrong and the patient continued to be supported mechanically and was extubated later that he was destined to be (Health Professional Council 2008: 1). Analysis is the fourth stage of Gibbs reflection cycle. This stage is meant to evaluate if the individual can make sense out of the incident. My analysis of the incident is that delegation should be accompanied with supervision. When the anesthesiologist delegated to his assistant, he should have supervised top ensure that his assistant administered the wrong drug. Consequently, analysis of the incident evidences the importance of adhering to the 5 right of medication: right drug, right patient, right route, right dose, and right time. The assistant failed to adhere to one the rights as he did not administer the right drug (Health Professional Council 2008: 1). Gibbs reflective cycle outlines conclusion as the fifth step in the reflection process. On the question as to what else I could have done, I could have been with the assistant as he withdrew the drug from the ampoule and confirmed with him if it was the right drug. This is since it is a protocol that prior to administration of a drug; it has to be confirmed by two different people. As pertains to the outcome of the incident since nothing bad happened to the patient aside from the long recovery and extubation of the patient, I feel that there is nothing I could have differently. My being there at the time I was, I feel was timely and my discovery of the wrong drug was also timely and effective in the incident that happened (Jane 2010: 1). In concluding the reflection according to Gibbs reflection cycle, my action plan would be to check the administration of the drug in my presence. I would also want to see to it that the 5 rights drug administration was adhered to in the face of such an incident. Identification and evaluation of relevant legislation and guidance Legislations are the laws that bind a particular profession and the performance of activities of that profession. With relevance to the incident reflected upon in this paper, the anesthesia rule has been reviewed. This is since it evaluates the effect that administration of a wrong medication can have on the patient. Concurrently, the legislation on professional conduct has been reviewed since every professional is legally bound by his profession in the performance of his activities. In reference to the incident, this pertains to the anesthesiologist and his assistant (Reason 2000: 320). Identification and evaluation of professional and ethical considerations A health care provider is professionally and ethically bound to perform activities that are not aimed at causing harm to the users. This is outlined in the professional code of conduct. In reflection of the incident that occurred, the assistant was ethically bound not to perform activities that would have put the life of the patient at risk. By the assistant administering a wrong drug to the patient, he was professionally jeopardizing the life of the patient as the patient took a longer time to be extubated and hence his recovery was longer than was expected. The assistant is required by his profession to be accountable for his actions in case the service user who is the patient had been harmed by his medication (Wheeler and Wheeler 2005: 257). Every professional is ethically bound by his profession to supervise tasks that he has asked other people to perform on his behalf. In reference to the incident that happened, it was the duty of the anesthesiologist to administer the reversal drug. However, he delegated this duty to his assistant who to his expectations the assistant had the required knowledge and skills to effectively and efficiently perform the task (Meadows 2002: 192). However, the anesthesiology failed to supervise the task since had he done so, he would have discovered that the assistant had withdrawn from the wrong ampoule and the negative effects in the patient would have been curtailed. This therefore necessitates the importance of supervise the tasks we delegate to others since accountability is never delegated. We will still be held responsible for the outcome of the tasks we are supposed to do but we delegate to others (Soeng 2008: 549). Identification and evaluation of communication issues Communication is essential for the success of any relationship and interaction between two individuals. In the health care set up, communication is important as the management of the patient is not solitary to one individual but requires the collaboration of all the diverse health workers. In the theatre where the incident occurred, communication is essential since the anesthesiologist, the surgeon and the nurse need to communicate with each other as in their diverse capacities, they each contribute to the safety of the surgical operation (Kelly 2004: 35). Communication is experienced at the commencement of the incident. This is illustrated when my colleague requests me to stand in for her as she went to take her lunch. This communication is important since if there was no one to take her place, the mistake in the administration of the wrong reversal of the anesthesia would have gone un noticed. This is an illustration of effective delegation that is achieved through proper communication since by my colleague communicating with me; we were both able to avoid a catastrophe that would have occurred (Kelly, 2004: 35). In the incident that occurred in theatre, there was continued communication with the surgeon and the anesthesiology as following completion of the surgery, the patient needed to be extubated to reverse the effects of the anesthesia. Communication is evidenced in the incident when the anesthesiologist communicates with the assistant to administer the reversal of the anesthesia. This had previously followed the communication of the doctor after successfully completing the surgery and hence needed the patient to be reversed so as not to be mechanically supported (Kelly 2004: 35). Communication is also evident in the incident as pertains to my role in the incident. Upon the realization that the assistant had administered a wrong drug, communication was important so as not to jeopardize the life of the patient. I communicated effectively to the assistant when I brought to his attention that he had administered the wrong medication to the patient. In the overall incident, communication can be rated as effective and as the reason why the patient did not have adverse effects as the mistake was communicated in due time and mitigation measures taken (Abeysekera 2005: 220). Discussion and appraisal of current research relating to the issue and development of recommendations Research has documented that medication errors have translated to increase in mortality and morbidity rates and has been attribute to cost more than $136 billion annually in the US. Drug effects as a result of medication errors have been documented to rise by $4,700 for every medication error that was capable of being prevented (Glavin 2010: 76). This is since a medication error translates to need for an increase in the diagnosis and in the monitoring of the patient. In addition, medication errors translate to increase in the level of care and the patient ends up spending more time than is actually required in the hospital recuperating from the wrong medication (National Patient Safety Agency 2010: 1). This is evidenced in the incident that occurred since though the patient did not experience harmful effects of the drug, extubation was delayed and hence the recovery of the patient. These are side effects of the wrong drug administration that could have been prevented if the assistant was more cautious and keen in drug administration (Cohen 2001: 25). Other than the effects that medication errors has on the patient, medication errors has been researched and documented to have negative effects on the hospital as pertains to the law suits that might be filed against the hospital. A study conducted revealed that $120, 722 was paid as indemnity payment to claimants, following medication errors. This translated to approximately $47.7 million per annum incurred as a result of preventable medication errors that occurred (Pinilla et al., 2006: 66). As pertains to the incident that happened, the patient and the relatives may not be made aware of the malpractice that occurred in the operating theatre. This is however against the rights of the patient as every patient has a right to disclosure of medications and procedures performed on him. Nothing much is outlined in the incident as the relatives have not featured anywhere. Research ahs however evidenced that such medication errors never get to the patients knowledge especially malpractice performed when the patient is unconscious like in theater and the relatives are not aware (Pinilla et al., 2006:66). This reflection paper recommends the use of failure mode effect analysis (FMEA) as an initiative to reduce the increase in the number of medication errors. FMEA aims at: recognizing the product and its propensity to fall prey of medication errors; stipulation of actions that could be implemented to reduce the occurrence of the medication errors, and documentation of the entire process (Mazur and Chen 2009: 868). This has been used by majority of the health care systems as a way of minimizing medication errors especially in the anesthesiology field. It has seen the reduction in mortalities attributed to anesthesia errors reduce considerably by 95% for a period of 15 years. The success of FMEA requires the networking of all health care professionals and the electronic sharing of the interventions undertaken by the health care profession by all health care providers. This limits the propensity of an individual to get away with a medication error with the purport that the patient is not aware like the incident that happened in the operating room. This therefore limits the medication errors performed by the health care professionals as they increase their likely hood of losing their licensure and their employment being terminated (Crane and Crane, 2006: 3). Use of Electronic medical Records (EMR) is another recommendation that this reflection paper proposes as an initiative to reduce the incident and the prevalence of medication errors. This is a replacement of all paper work as the information of the patient is shared among health workers electronically. This reduces the propensity of errors going unrecognized since the information is accessible to all health care professionals. As pertains to the incident that occurred in the operating theater, the assistant would have had to enter the drug electronically and he would have realized that the drug he was about to administer was the wrong one. Critics have voiced lack of patient confidentiality as a shortcoming of EMR but HIPAA (Health Information Portability Accountability Act) has limited the people who have access to EMR. This means that this recommendation is a viable venture to reduce medication errors (Crane and Crane, 2006: 3). The use of the six sigma quality assurance method is another recommendation by this reflection paper that can reduce medication errors (Esinali, 2005: 51). Conclusion Reflection is important so as to gain in depth understanding of an issue. As pertains to the incident that happened, reflection enabled me to learn so much about medication errors than I knew. Reflection has been documented to breed research since it bombards an individual with questions that can only be answered through carrying out research. From this reflection paper, I gained an insight on the professional and legislations that bind medication errors and drug administration. Consequently, I was able to understand the ethical consideration of medication errors and also gained an insight on communication issues. I was also in a position to investigate research that has been previously carried out and hence was able to come up with the two recommendations of this reflection. This reflection therefore recommends EMR, Sigma Six, and FMEA as effective ventures in reducing medication errors. Bibliography Abeysekera et al. (2005) Drug Errors in Anesthetic Practice: a review of 896 reports from the Australian incident monitoring study database. Anesthesia, 60 pp.220-227. Cohen, H. (2001). Shrinking medication errors down to size: What you can do about this far-reaching problem. Nursing Management, 32(10), 25-30. Crane, J., & Crane, F., (2006), Preventing medication errors in hospitals through a systems approach and technological innovation: A prescription for 2010, Hospital Topics, 84(4), 3-8. Esimai, G. (2005). Lean six sigma reduces medication errors. Quality Progress, 38(4), 51-57. Glavin, R. (2010) Drug errors: consequences, mechanism, and avoidance. British Journal of Anesthesia, 105(1): pp.76-82. Health Profession Council (2008) Standards of Conduct Performance and Ethics. [online] Available at: http://www.hpc-uk.org/assets/documents/10002367FINALcopyofSCPEjuly2008.pdf. [Accessed 3/December/ 2011]. Jane, C. (2010). Implementing Human Factors in Health Care. Available at: www.institute.nhs.uk/images/documents/safecare/human-factors-How-to-Guide-V1.2.pdf. [Accessed on 3/ December/2011]. Kelly, W. (2004). Medication errors: Lessons learned and actions needed. Professional Safety, 49(7), 35-41 Mazur, L., & Chen, S. (. (2009). Recommendations for effective management of medication errors. IIE Annual Conference.Proceedings, , 868-873. Meadows, G. (2002). Safeguarding patients against medication errors. Nursing Economics, 20(4), 192-4. National Patient Safety Agency, (2010). Feasibility of confirming drugs administered during anesthesia. A collaborative project of the National Patient Safety Agency, Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland. Available at: http://www.nrls.npsa.nhs.uk/resources/clinical-health-specialty/anaesthesia/?entryid45=59845. [Accessed on 3/ December/2011]. Pinilla, J., Murillo, C., Carrasco, G., & Humet, C., (2006). Case-control analysis of the financial cost of medication errors in hospitalized patients, The European Journal of Health Economics: HEPAC, 7(1), 66-71. Reason, J. (2000) Human Error Model and Management. BMJ, 2000: 320. Seong, Y. (2008). Analysis on medication errors to understand the trends: A case study at a large hospital. IIE Annual Conference.Proceedings, , 549-553. Wheeler and Wheeler. (2005) Medication Errors in Anesthesia and Ethical Care. Anesthesia, 60. pp.257-273 Read More