Safe Health Care: Are We up to It - Case Study Example

Safe Health care: Are We up to It? Communication in this scenario has been quite a challenge for almost all the parties involved and this can put the safety of the patient at risk. From the word go it is clear that adequate information is not being relayed and necessary questions are not being asked. The first instance is where the clerk was not aware of the time of Ivan’s surgery. It is understandable that he could not have known but he was obliged to ask the relevant authority so as to inform Ivan. Ivan being diabetic also needs to keep eating intermittently therefore he needed to be told so as to ask further questions about his condition. The lady asking Ivan to change clothes into hospital gown did not introduce herself and this could have created nervousness on the side of Ivan. The lady did not ask about any other condition that Ivan may have been suffering from and she could have been informed about the diabetes case. Ivan on the other hand failed to volunteer this vital information on the basis of assumption that his records show it. The anaesthetist on being informed of Ivan’s light-headedness should have sort to investigate all avenues possible but not to conclude and ask for HbA1c alone. The circulating nurse noticed the problem with the identification sticker when a wrong incision had already been done while such information should have been vitally important to have uncovered earlier enough. These scenarios in both their individual capacity as well as collectively have come to compromise Ivan’s safety as a patient. 1. Fundamental attribution error – this is an error where in this clinical scenario was conveyed by the anaesthetist whereby they underestimated the reasons behind Ivan being ‘a bit lightheaded’. This is more common when the symptoms being experienced are more of common occurrences and being lightheaded is one of them when one is under nervous tension. Overconfidence bias – this is the other that this scenario posed. Here the anaesthetist was not objective enough as to try to investigate all the possible causes of Ivan being ‘a bit lightheaded’. This occurs mostly where one is in a hurry and this is a perfect example where they were already late to start the operation on Ivan. 2. For patients who have received a pre-operation sedative, conducting pre-operation checking processes posses a huge risk (Berwick and Leape 2000). This is as a result if the sedative acting as a hindrance to the process of distinguishing sedative effects and symptoms of possible ailments that could require change in operation procedures. Sedatives are known to also affect the brain functioning of the patient therefore even the answers they give to questions about their health may be incorrect. This risk can be minimised be having pre-operation checking process before a preoperational sedative or anxiolytic is administered. Tests should be performed where possible on the patient in case where the sedative was administered before important information was uncovered so as to verify the truth in the patient’s responses. 3. Surgical patients are exposed to risks during surgery which are at times avoidable while others are inevitable depending on the circumstances. It is understood that patients are always expecting to be well taken care of and that they are in responsible and skilled hands of surgeons and supporting staff during and after the operation. It is therefore important for the medical staff to use the best means possible to make this a reality. The surgery safety checklist is one such measure that reduces the chances of causing injury to the patient or even death during an operation. The checklist provides the most basic of processes and procedures to follow in order to come up with a comprehensive analysis of the patient’s condition (Berwick and Leape 2000). The checklist ensures that the medical personnel follow a standard procedure that is widely accepted and one that leads into protecting the patient against potential risk of injury or death. 4. The outcome of this patient’s surgery was one that was uncalled for. It is evident that negligence was to blame for double incision where one was a wrong one. Someone has to take the blame for this and it is far not within the realms of the patient. The medical personnel should take the blame. The medical practitioners take the responsibility of conducting their duties with reasonable care and diligence and this case proves otherwise. It is out of sheer luck that the operations was a success despite the hitches experienced, otherwise, the case could have been quite different if Ivan suffered injuries further than this. In actual sense the wrong incision was an injury on its own account caused directly by the medical staff. Berwick and Leape (2000) suggest blaming individuals on scenarios like these requires thorough insight. The reason for this is that a mistake by an individual may most likely be one that is indirectly shared. A case in point is this scenario where the surgeon is acting on the information provided by them by their supporting staff. Therefore, as much as they are the ones who personally made the wrong incision, they were not solely liable and to some extent they could quite remotely liable. 5. Clinical governance in this scenario is one that if well implemented could have evaded the problems witnessed. Clinical governance deals with the quality of care to patients and in this scenario the quality was way below par. The role of clinical governance is to ensure that the personnel are well trained to follow laid procedures, there id adequate clinical effectiveness and that the risks associated with a surgical procedure are minimised in highest levels as humanly possible (Scally and Donaldson 1998). 6. IIMS reporting and RCA in this scenario will be of important help in that the patient under question will be operated on according to their specific medical conditions other than the ones resulting to the surgery. Diabetes in this case is a case to critically consider while performing a surgical operation and for that reason considering this fact goes a long way in determining the surgical approach to take (Proye, et al. 2010). 7. Principles of open disclosure relate to the discussions held with a patient in order to disclose injuries caused to them while under care of medical personnel. This discussion should be open and timely as much as possible (NSW Health, 2010). In this situation Ivan was informed almost immediately after waking up from the anaesthesia and was given the full information on the incident. An apology was sought and the information was kept under the confidentiality it deserves. References NSW Health (2010). Open disclosure: key principles of open disclosure. Retrieved 10 June 2010, from http://www.health.nsw.gov.au/quality/opendisc/index.asp Proye, C. et al. (2010). Intraoperative insulin measurement during surgical management of insulinomas. World Journal of Surgery. Springer: New York. 22, 12. Scally, G. and Donaldson, L. J. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 61-65. Berwick, D. M. and Leape, L. L. (2000). Safe health care: Are we up to it? BMJ. 18; 320 (7237). 725–726. Read More