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