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Introduction

This report investigates a 76-year-old lady, who was referred to Ocular Plastics service, for a right canthopexy, however wrong site surgery was also commenced on the left eye and was stopped but only after a small incision had occurred. This report concerns that wrong site surgery. 

A canthopexy surgery was recommended to the patient and a biopsy was also scheduled to the right side of the eye. The decision to operate was taken up and the consent for both the procedures taken from the patient. This report found several faults while the surgery was undertaken. However, the key point of investigation that has been undertaken in the report dealing with the identification of the Inter-disciplinary communication in patient safety, poor collaborative practice and safer surgery checklist that have occurred. Recommendations will be made in the report concerning the ophthalmologist and the interdisciplinary team members to ensure that mistakes are reduced and improve patient safety. The area that can be improved will include the duties performed by the doctors and the overall task performed by the nurses. According to NMC (2018), while exploring this report, it is important to respect the patient’s privacy and anonymised all names to maintain confidentiality. 

Main Body

Theme 1 

The first theme was inter-disciplinary communication in Patient Safety. The brief checklist (WHO, 2012) is important as it helps ensure team members follow the patient safety steps critical in a consistent manner (NMC, 2018a). the safe surgery checklist should be followed by the team members before the surgery as this will help in the reduction of complications. By following the checklist, the minimisation of avoidable risks can be taken up by reduction in the mortality rate of patients who will undergo surgery National Institute of Health Care Excellence (NICE, 2018, NG180). A team briefing before surgery is required by the team members (Leong et al., 2017) so that the understanding of the requirements that are presented in the list is shared by all the members present in the surgical team (Weiser and Haynes, 2018). Identification of the level of skill, equipment and staffing requirements and the preparation for anticipatory problems can be taken up in the brief with the checklist's help. The briefing is also important as it helps the interdisciplinary team members to come face to face and discuss intricate details about the surgery and the type of incision that will be made in the patient (Bailey et al., 2019). This helps in the reduction of any mistakes and ensures patient safety. In this report the surgeon was not present when the timeout checklist was being completed. The non-clearance at what point the surgeon had joined the team also showed a lack of communication among the members. The collaborative effort of the team was seen as missing (Grocott et al., 2022). The doctor was not present in the briefing room and was in the scrubbed room while the meeting was held. Any update on the procedure was not made known to the doctor. The procedure taken up for the surgery was not usual, and a time-out process was not followed in the operation room Before making any incisions or beginning the surgery, the entire surgical team assesses the individual's identity, the technique, and the surgical site. The timeout is also a place set aside for members of the team to raise any issues they may have regarding the safety of the patient or the treatment (Papadakis et al., 2019). The message on the whiteboard was wrong and no one had double checked the excision of the lesions. As a result the wrong surgery of the patient was seen.

Theme 2 

Collaboration within the interdisciplinary team was poor. The care plan was not completed by the surgeon or any other members of the disciplinary team members. The requirement of checking the care plan is important because the care plan is made according to the needs and requirements of the individual patient (Cushley et al., 2021). Similarly, in this case Mrs. P’s care plan was made according to her needs and surgery. The procedure originally decided for the patient was right canthopexy, but after the timeout it was noticed that it changed to left eye canthopexy. This shows that the co-ordination, communication gap and poor teamwork between the interdisciplinary team members is evident. The lack of responsibility on the part of the operating department practitioner can also be taken up. Post aesthetic observation and patient assessment was not done by the OPD (Chapman et al., 2020). The rate of heartbeat and the respiration rates were not monitored. In the absence of this documentation any decline or changes in the stability of the patient cannot be determined. Sedation score was also not documented by the OPD. All this was not followed by the OPD as he had left the room just after administering anaesthesia. The main reason for this is that the time out for surgery has commenced (Madge and Khair, 2000). Local anesthesia was provided to the patient, so the anesthetist does not have to be present inside the room (Reed et al., 2012). The team was also negligent in documentation of the procedure written on the white board. Only left side was mentioned but the consent form mentioned right eye surgery (Dobbs et al., 2021). This lack of correct documentation about the excision technique resulted in the wrong surgery of the patient.

Theme 3 

Surgical Safety Checklist

Surgical safety checklist not done before Mrs. P surgery. There was a lack of negligence from the perspective of the operating surgeon. The operating surgeon was not present, and this showed no attention paid to the patients. The safer surgery checklist should have been used (WHO, 2009). This will involve an operating surgeon who will take active involvement in making sure that the person is safe and thus the whole surgery can be done very easily. Moreover, the lateral excision should have been done by keeping a surgeon and then only the process will be considered valid (Nancarrow et al., 2013). During the entire process of administering an anesthetic, the surgeon should have been present but there was no surgeon present at that exact time. Moreover, while performing the entire process, there should have been A Bilateral block and this should be required for performing the procedures (Tierney et al., 2019). The factors that created this situation were total negligence from interdisciplinary team members. The interdisciplinary team members competent and follow roles and responsibility through the whole process of treatment of the patient more cautiously. Moreover, when any new medicines were provided to the patient, they should be given prior consent from the surgeon. This will become the safety health practice that should be implemented in hospitals before performing any surgery (NHS, 2019). This anesthetic medicine is provided to the person before performing surgery, and this should be done by keeping the surgeon, and only this will be taken as a safety measure to treat the patients. The anesthesia performed on the patient required authorization from the patient and the surgeon, and then only the whole surgery process is continued, in this case there was no proper authorisation taken from the patient's side. This has created more problems as there were no rules followed during providing anesthesia to the patient. 

Conclusion 

It can be concluded that there were several faults on the part of the interdisciplinary team members in dealing with the situation. The main themes that were identified in the case study are lack of communication and efficiency on the part of the team members. Along with that the documentation process of the surgical excision was not properly noted by the junior team. The lack of completion of the care plan by the OPD can be seen as the local anesthesia was not given to the patient. Therefore, his presence did not matter in the operating room. Recommendations have been provided that will help in the increased efficiency of the communication and the documentation process. Following SBAR and correct delegation of tasks should have been taken up by the interdisciplinary team.

Recommendation

The following identify what should be happening. Your recommendations should identify how this can be supported (solutions).

  1. It is strongly recommended that any medical procedure that is performed by nurses should involve the presence of a surgeon and this will help in making sure that there will be no negative outcomes from the patient's side (WHO, 2009).
  2. Develop clear and concise protocols that outline the steps involved in each procedure. This can help ensure that all advanced nurse practitioners are following the same steps and procedures with the help of standardized protocols.
  3. Implementation of checklists by creating checklists that advanced nurse practitioners can use before, during, and after each procedure to help ensure that nothing is missed.
  4. Establishing of clear goals so that every team member can understand the goals of the patient care plan.
  5. Encouraging open communication that will help in the creation of culture and fostering an environment of trust by asking and reviewing any problematic questions regarding the patient.
  6. There should be site marking that should have been done to indicate the surgical sites, but in this case, the site marked and the surgery performed was different. Involvement of the patient is required and explaining the marking's objective to the patient and make sure they comprehend the process to involve them in the marking process.
  7. Use a uniform technique of site marking which is applied to all healthcare institutions and providers. Every member of the medical team can benefit from the marking being clear and simple to understand in this way.(Pennington and Garside, 2019)..
  8. Patient-centered care will be maximized with the help of increased communication between health care professionals and patients. SBAR should be followed by the interdisciplinary team members who will help understand the same information about the patient (Surrey, 2021).
  9. Collaborating and working together can reduce stress and help in finding innovative solutions for patient care. Assessment and recommendation about the patient should be taken up by the interdisciplinary team. (REF)

Appendix 

The case study deals with Mrs. P, an old lady referred to Ocular Plastics service. Four procedures have been provided to the patient. A canthopexy surgery was recommended to the patient and a biopsy was also scheduled to the right side of the eye. The decision to operate was taken up and the patient consented for both procedures. The surgery was undertaken and had several faults in it.

References

Bailey, C.R. et al. (2019) “Guidelines for day‐case surgery 2019,” Anaesthesia, 74(6), pp. 778–792. Available at: https://doi.org/10.1111/anae.14639.

Centre for Perioperative Care (2015). T he National Safety Standards for Invasive Procedures (NatSSIPs). Available at https://cpoc.org.uk/guidelines-resources-guidelines/national-safety-standards-invasive-procedures-natssips 

Chapman, R. et al. (2020) “Providing safe and effective surgical care during the COVID-19 outbreak in the UK – changing strategies,” International Journal of Health Policy and Management, 1(2), pp. 23–34. Available at: https://doi.org/10.34172/ijhpm.2020.112.

Cushley, C. et al. (2021) “Writing’s on the wall: Improving the WHO surgical safety checklist,” BMJ Open Quality, 10(1), pp. 20–25. Available at: https://doi.org/10.1136/bmjoq-2020-001086.

Department of Health (DOH) (2004). HBN26 Facilities for surgical procedures: volume 1. TSO. London. 

Dobbs, T.D. et al. (2021) “Surgical activity in England and Wales during the covid-19 pandemic: A nationwide observational cohort study,” British Journal of Anaesthesia, 127(2), pp. 196–204. Available at: https://doi.org/10.1016/j.bja.2021.05.001.

Grocott, M.P. et al. (2022) “Tranexamic acid for safer surgery: The time is now,” British Journal of Surgery, 109(12), pp. 1182–1183. Available at: https://doi.org/10.1093/bjs/znac252.

https://www.surrey.ac.uk/news/most-important-person-multidisciplinary-team (Accessed:18/03/2023)

Jain, D., Sharma, R. and Reddy, S. (2018) “Who safe surgery checklist: Barriers to universal acceptance,” Journal of Anaesthesiology Clinical Pharmacology, 34(1), pp. 7–13. Available at: https://doi.org/10.4103/joacp.joacp_307_16.

Leong, K.B. et al. (2017) “Effects of perioperative briefing and Debriefing on Patient Safety: A Prospective Intervention Study,” BMJ Open , 7(12), pp. 34–45. Available at: https://doi.org/10.1136/bmjopen-2017-018367.

Madge, S. and Khair, K. (2000) “Multidisciplinary teams in the United Kingdom: Problems and solutions,” Journal of Pediatric Nursing, 15(2), pp. 131–134. Available at: https://doi.org/10.1053/jn.2000.5516.

Moletta, L. et al. (2020) “International guidelines and recommendations for surgery during covid19 pandemic: A systematic review,” International Journal of Surgery, 79(3), pp. 180–188. Available at: https://doi.org/10.1016/j.ijsu.2020.05.061.

Nancarrow, S.A. et al. (2013) “Ten principles of good interdisciplinary team work,” Human Resources for Health, 11(1), pp. 23–34. Available at: https://doi.org/10.1186/1478-4491-11-19.

NHS (2019) Information sharing in Multidisciplinary Teams (MDTs), NHS choices. NHS. Available at: https://transform.england.nhs.uk/information-governance/guidance/informationgovernance-guidance-support-multidisciplinary-teams-mdts/ (Accessed: March 18, 2023).

Papadakis, M., Meiwandi, A. and Grzybowski, A. (2019) “The who safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety,” International Journal of Surgery , 69, pp. 19–22. Available at: https://doi.org/10.1016/j.ijsu.2019.07.006.

Pennington, B. and Garside, J. (2019) “The Perioperative Team Brief: A patient safety initiative or another tick-box exercise?,” Journal of Perioperative Practice, 29(12), pp. 408–412. Available at: https://doi.org/10.1177/1750458919845828.

Reed, K.L., Malamed, S.F. and Fonner, A.M. (2012) “Local anesthesia part 2: Technical considerations,” Anesthesia Progress , 59(3), pp. 127–137. Available at: https://doi.org/10.2344/0003-3006-59.3.127.

Surrey (2021) The most important person in the multidisciplinary team, The most important person in the multidisciplinary team | University of Surrey. Available at:

 Tierney, E. et al. (2019). “Interdisciplinary team working in the Irish Primary Healthcare System:Analysis of ‘invisible’ bottom up innovations using normalisation process theory,” Health Policy, 123(11), pp. 1083–1092. Available at: https://doi.org/10.1016/j.healthpol.2019.09.002.

Weiser, T.G. and Haynes, A.B. (2018) “Ten years of the Surgical Safety Checklist,” British Journal of Surgery, 105(8), pp. 927–929. Available at: https://doi.org/10.1002/bjs.10907.entre

WHO (2012) Safe surgery , World Health Organization . World Health Organization. Available at: https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery (Accessed: April 20, 2023).

World Health Organization (WHO) (2009). Guidelines for Safe Surgery, Safe Surgery Saves Lives. Available at: file:///C:/Users/BETHAN~1.GOO/AppData/Local/Temp/MicrosoftEdgeDownloads/b72e30fe-1421-487c-b484-3cf3ef054ada/9789241598552_eng.pdf 

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