BSc in Intra and Perioperative Practice - Essay Example

? BSc (Hons) in Intra and Perioperative Practice Professional Practice Development (HC3075) Reflective Assignment Number: Word Count (2031) Introduction One of the central concepts of modern healthcare is that of evidence-based practice (EBP), involving the use of scientific research to provide the best care for patients and their families (LoBiondo-Wood and Haber, 2005). In many cases, EBP shapes the way that healthcare treatments are delivered – from routine medical practices to nurse interactions with patient families. Because of the importance of EBP, it can be useful to integrate reflections from personal experiences with those of the scientific research to give a well-rounded picture. There are many ways of structuring such reflections to ensure that they are maximally productive; the one that will be used to structure this research and to explore an incident is an adaptation of Gibb’s Reflective Cycle (Quinn, 1998). The incident in question happened about four years ago in the operating department of our hospital, where I was working as a scrub practitioner. It occurred during an open appendectomy, when I discovered that a piece of gauze was missing during the second-stage swab count and before closing the cavity. I informed the surgeon after the circulating practitioner and I repeated our count. I as the scrub practitioner had the responsibility of looking for the instrument table, mayo stand and sterile operating field. The circulating practitioner was responsible for checking the bins and the operating theatre floor. At the same time, the surgeon checked inside the patient's wound, but the missing piece of gauze could not be located. At this point, the operating supervisor was informed, and he undertook a double check for the piece of gauze before calling for an X-ray of the patient's cavity. Fortunately, the X-ray revealed that the gauze had not been left inside the patient. The patient was then considered safe and could be transferred to the recovery room. Later analysis revealed several mistakes that have led to this incident. Feelings There are a variety of feelings associated with such an incident. The main feeling at the time was a sense of fear that the missing piece of gauze would pose a danger to the patient. Although this fear was quickly eradicated by performing the x-ray on the patient as recommended (Cima, et al., 2008), it was painful to think that a miscommunication and miscalculation could cause harm to a living being. Many guidelines suggest that the failure to remove swabs and gauzes from patients can stem from a miscommunication (Gibbs and Auerbach, 2001), and events such as these can be often prevented by having a pre-operative de-briefing session (Nilsson, et al., 2010). In this case, there may have been some elements in which it would be beneficial to be better prepared, despite the customary de-briefing and knowing our procedures on how to prevent retained gauzes. It was only such an evaluation (the second-stage swab count) which allowed us to discover the error at such an early stage. Despite this, I was extremely worried about the patient and his feelings in relation to the incident, particularly as the missing gauze was not located. There are a huge number of guidelines (such as the World Health Organization [WHO] Guidelines for Safe Surgery []) which need to be followed to the letter, which obviously did not occur in this case due to human error. Evaluation and Analysis A common feature in the literature highlights the importance of counting, and this incident goes to show how important this factor is. Counting has been used as a tool to see how common discrepancies in the surgical tools number are during surgery (Ahmad, et al., 2003); one study found 29 discrepancies in counting between just 19 surgeries, although the majority of these were just misplaced items (Greenburg, et al., 2008). Riley et al. (2006) suggest that the major improvement that can be made in such situations revolves around communication; an important tool for every aspect of surgery (Reid and Bromiley, 2012). Effective team-work is also deemed important (Leonard, et al., 2004). In this case, it allowed different members of the team to inspect different areas of the operating theatre to successfully decide that the missing gauze was not merely misplaced. The fact that the missing gauze was not found suggests that there were some errors in teamwork that should be improved to ensure that patient safety levels are maintained (Leonard, et al., 2004). Sexton et al. (2000) suggest that 44,000-98,000 patients each year die from preventable deaths, such as those caused by errors in judgment, teamwork or high levels of stress amongst the team. Interestingly, this makes medical error the eighth biggest killer in the survey (Sexton, 2000), and this highlights the importance of evidence-based practice and the need to learn from previous mistakes. It should also be noted that all humans are prone to error (Wan, et al., 2009), which makes it all the more important to do swab counts to try to find missing gauze. Without these checks, the medical equipment could have been left inside the patient, as it so often is (Bani-Hani, et al., 2005), and could have caused much more damage to the patient, as well as serious medical and non-medical stress to themselves and their family (Dierks, et al., 2004). This again highlights the importance of learning from previous information to ensure that practice is kept to the highest standards. There are certain other risk factors that have been identified that heighten the risk of items being left inside surgical wounds, including having an obese patient, doing emergency surgery, and unplanned changes during a procedure (Girard, 2004). These things are generally unavoidable (Wan, et al., 2009), but good communication and protection against carelessness are time and time again recommended as precautions against these things to prevent incidents like the one described above (Lincourt, et al., 2007). These unpreventable things can be tackled with human decisions, such as swab counts (Dierks, et al., 2004), communication, and proper training about the risks (Gibbs and Auerbach, 2001). Knowledge of the severity of misplaced items during surgery has also been shown to be a good precaution against this type of incident (Bani-Hani, et al., 2005). It is important to continually educate the nurse and other clinical staff members to ensure that everyone has the correct idea (Lincourt, et al., 2007). One study even suggests that having the circulating nurse conduct the counts (someone who has a high level of education and training regarding this element of surgery) is of the utmost importance in preventing this type of problem (Jackson and Brady, 2008). Finally, it is important for clinical staff to be aware of the complications that can arise from leaving an instrument or sponge in a patient during surgery (Bani-Hani, et al., 2005), which can include pain, infection and abscesses (Jackson and Brady, 2008). As many people who enter the healthcare profession do so as part of a larger desire to care (Cima, et al., 2008), making these staff members aware of the trouble that these instruments can cause patients is definitely an effective way of increasing care during the procedure (Ahmad, et al., 2003) and helping eliminate the human errors outlined above. Another thing that has been suggested by the literature is relying on new technological research to increase the likelihood of finding retained surgical sponges and ensuring that misplaced items can be found. One such option includes electronic tagging of items to be used during surgery (Fabian, 2005), an expensive but extremely effective method. These options may be complex and expensive but are worth considering in any attempt to tackle the problem. Summary and Recommendations One of the major problems with this surgery was due to human error in the operating room. Although all the correct checks were carried out at appropriate times, the gauze could not be located and, therefore, could have been left inside the patient, causing considerable problems. There are several reasons why this could have happened. The first could be that the second stage swab count could have been done incorrectly, leading the team to believe that a swab was missing in error. There are suggestions, as outlined above, that this type of error could be avoided by having someone highly trained in swab counts, and by ensuring that these checks are carried out numerous times during the surgery, with recounts being done if necessary. Effective communication between the team members is what led to the x-ray and other preventative methods carried out to ensure that the gauze was not left in the patient, as per the guidelines (Cima, et al., 2008). However, the communication could have been seriously improved to prevent the gauze going missing in the first place. Continual updates on where the surgical instruments are during the procedure, as well as continuous and frequent counting exercises are the most important efforts to communicate during this type of surgery (Gibbs and Auerbach, 2001). Additionally, the scrub practitioner has a duty to inform the correct members of staff as to the progress of these counts as often as possible without disturbing the surgery (Greenburg, et al., 2008), which perhaps could have been an improvement on my part. Teamwork is also extremely important. In this case, the team worked well together to find the missing gauze, including alerting the correct member of the team about the missing item to get an x-ray completed as soon as possible. However, as the missing gauze was not located, there is a suggestion that teamwork could have been better and more effort could have been made in finding the misplaced item, as recommended by the literature outlined above. This type of teamwork can, and should, be strengthened by ensuring that the communication steps are handled correctly as outlined above. “Lewin’s Change Management Model”, developed by Kurt Lewin (Schein, 1996) describes a good method by which to manage change and can be applied to this situation. There are three main stages in this approach; unfreeze, change and refreeze, which will be discussed below. 1. Unfreeze. The first stage in Lewin’s model recognizes the importance of preparing for change and ensuring that all the relevant staff members (in this case, operating room staff) understand the necessity for change and what it will involve. As outlined above, the most important aspect of preventing missing instruments and gauze in surgery is targeting human error, which means that this needs to be targeted in the unfreeze stage. Firstly, I recommend posters and leaflets to be circulated amongst operating room (OR) staff, which will alert them to the complications of missing swabs and surgical items and will feature statistics of how common this problem is. This will then help educate everyone on the importance of swab counts, including all relevant OR staff (as mentioned in the discussion above), during and after the procedure, and on how many counts will be completed during the task. 2. Change. The change stage involves OR staff understanding the steps that need implementing (as outlined above) to prevent similar scenarios happening again. This involves more vigorously looking out for surgical instruments during the procedure as well as ensuring that swab counts are carried out correctly, based on the literature suggested in the unfreeze step of this process. As communication is paramount at this stage, regular meetings should be held to ensure that progress is occurring and that everyone understands the steps that need to be taken during surgery. Additionally, this stage will involve going over the procedure that needs to be done in the event that a count reveals a missing instrument, gauze or swab, such as the x-ray that occurred in this scenario, and ensuring that these things happen every time. 3. Refreeze. This step is important for ensuring that all the changes based on the literature continue throughout the OR procedures. This will involve ensuring that everyone has knowledge and continuous education about the importance of swab counts, and regular meetings to ensure that everything is going correctly. Following the above steps should minimize the number of similar incidents and ensure that missing surgical equipment can always be found in the OR without having to resort to x-rays (if possible), and that missing equipment is always found in the suitable manner if needed. References Ahmad, G., Attiq-ur-Rehman, S. and Anjum, M.Z., 2003. Retained sponge after abdominal surgery. Journal of the College of Physicians and Surgeons–Pakistan: JCPSP, 13, 640. Bani-Hani, K.E., Gharaibeh, K.A. and Yagha, R.J., 2005. Retained surgical sponges (gossypiboma). Asian Journal of Surgery, 28, 109–115. Cima, R.R., Kollengode, A., Garnatz, J., Storsveen, A., Weisbrod, C. and Deschamps, C., 2008. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. Journal of the American College of Surgeons, 207, 80–87. Dierks, M.M., Christian, C.K., Roth, E.M. and Sheridan, T.B., 2004. Healthcare safety: the impact of disabling safety protocols. 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