Introduction
As a student of operating department practice (ODP), I will reflect on my experience when I was in a clinical placement at a hospital. Precisely, my reflection will be based on my experience with a 30-year-old patient who undertook a surgery. The Gibbs Reflective Cycle (1998) was used to analyze the case study applied in this reflection and concentrates on patient’s holistic care, multidisciplinary team collaboration and communication (The University of Edinburgh, 2020). In this reflection, confidentiality was protected based on the Health and Care Professions Council (HCPC, 2016) and the Data Protection Act (1998) in the United Kingdom. As a result, the patient name, location and trust are anonymised in the paper. Precisely, the patient name will be anonymised to safeguard his confidentiality and will be referred to as Mr B. I will explain the care provided in guaranteeing sterile and safe environment in the pre-operative and post-operative environment. I will demonstrate an understanding and appreciation of the way to utilize specific standard procedures, measures and tools to deliver premium conditions for healing. Essentially, Fook and Garner, eds. (2012) argued that reflection is the dynamic process of evaluating, analysing, and reviewing experiences, applying theoretical ideas or past learning to facilitate improvements in the future. Fundamentally, reflection is a type of mental processing with an aim and expected outcome that is utilized to comparatively complex ideas for which there lack a clear solution. The benefits of reflection, when used among healthcare practitioners, including ODP, is crucial to enhancing skills and also appropriate for handling feelings after essential incidents. The effectiveness of reflection is founded on coaching and practice based on the reflective cycle (The University of Edinburgh, 2020). The Gibbs reflective cycle is made up of six stages. The Description is the first stage where the event is explained comprehensively while the second stage will present the assessment of Feelings of the reflector. Moreover, the Evaluation is the third stage which concentrates on the experience’s pros and cons, and the outcome of the experience. The fourth stage which concentrates on Analysis of the incident and the reasons happened the way they did and individual contributions to it (The University of Edinburgh, 2020). The Conclusion is the fifth stage which describes what could have been completed differently and the reason it was not completed and the learnt lessons. Finally, the Action plan is in the sixth stage, which concentrates on steps and preparation to facilitate improvements and optimum experience in the future.
Description
Patient B is a boy, seven years old, was scheduled to undergo a surgery as a corrective procedure for congenital palate and cleft lip. The patient was brought in the pre-anaesthetic clinic (PAC) by a nurse and me (student of the operating department practitioner). The patient had challenges with food intake. In the first year of his life, it was challenging for him to suck from his mother’s nipples or a bottle due to the size and shape of the deformity. Although various interventions and different techniques of feeding have been utilized, her growth has been eliminated because of malnourishment. As he grew up, he was able to consume solid foods, but he experienced challenges in swallowing it and had diverse spells of sinus infections because food elements were being compelled into the open sinuses.
The operating departing practitioner (ODP) helped the patient before the surgery and delivered personalised care. In the first stage of care, the preoperative phase, the patient is observed to be anxious, unceasingly crying and turning down her caregivers. At this point, the ODP initiated a communication with the patient and caregivers in order to ease anxiety. Besides, ODP started to prepare a different kind of drugs and specialist equipment such as intravenous devices and equipment and anaesthetic machines to safely maintain airway of the patient in the course of the operation. Patient A refused an intravenous (IV) line of anaesthetics, and he started crying uncontrollably once injections were tried. Caregivers comforted him, but they did not seem to have any power over the patient’s reactions and behaviours. Fortunately, the IV line was successfully inserted. After the sedation, the anaesthetists ensured that the patient is stabilized and that the airway was steady. When the surgeon was about to start the operation, he asked the multidisciplinary team to confirm the patient information. Unfortunately, it was established that the wrong patient had been brought in the theatre. The surgeon realized that he was supposed to conduct surgery on a different patient who was still seven years old, but I had interchanged their identification tags. The patient asked the patient to be woken up, and the drugs were administered. At this point, I offered to reduce the anxiety of the patient. I also provided support to the client until he successfully recovered from the impacts of the anaesthesia.
Feelings
Before the incident, I was in a good mood because it was my first time I was involved in practical work as a student of operating department practice in the hospital. However, it was revealed that the surgery was almost conducted on the wrong person (near-miss). I felt sad and disappointed that such an error was made. More significantly, a mistake of such kind could have been potentially tragic and disastrous if it had gone unidentified. I was scared, sad and dejected because I participated in bringing the patient to the pre-operative clinic. I thought about it, and I realized that such an error had the potential to contribute to fatal consequences which could force the multidisciplinary team to resign or terminate their careers. On the other hand, the only good feeling I had was that there was an admission of error by the Health Care Assistant (HCA) who confessed that she made an error while producing the identification tags.
Evaluation
From the incident, both positive and negative elements were identified. The key negative element was the patient’s misidentification which could be a source of disaster if the mistake was not noted before the surgery. To deal with the risk of misidentification, the WHO has suggested that all patient identification, specimen quantity and description are correct (WHO 2020). A negative element of the incident was the Health Care Assistant’s wrong production of the documentation labels at the patient ward. It is essential that after the production of identification tag, it is precisely checked with the patient prior to it being utilized as a patient’s label for items and wrist band tag. On the other hand, the error was identified before it occurred; thus, it was prevented. The multidisciplinary team detected the problem hence prevented an incident from occurring. The HCA also owned up to the fact that printing incorrect labels and stickers and failing to double-check with the patient is an unfortunate practice. The incident could have been corrected if the Health Care Assistant had asked the family of the patient about the information provided before releasing her to the theatre. The Operating Departing Practitioners and Surgeon detected the problem after they realized that the details and name were wrong. In so doing, it stopped a “never events”. Based on the National Health Service Improvement, are severe incidents that are completely avoidable because safety or guidance recommendations offering strong systemic protective barriers exist at a national level and must have been executed by all health care practitioners (NHS Improvement 2020). As a student of operating department practice (SODP), I admitted my limitations in this incident because I did not look at the specimen book; hence I did consult the HCA. Despite the specimen responsibility lying with all team members of the multidisciplinary team, but the professional accountability is bestowed on the scrub practitioner and the surgeon.
Analysis
The Department of Health and Social Care (2020) argues that health professions and organizations have an obligation to deliver safe and quality care, and this must be predictable to the community they serve. The 6Cs are the value base for facilitating change in health care delivery and are were established via Compassion in practice (Baillie 2017). The 6Cs included commitment, courage, communication, competence, compassion, and care. The 6Cs are entrenched in the routine health care and are a collection of compassionate care which permits practitioners to function in a safe, efficient, and effective manner. The 6Cs guarantee the safety of the patients and that health care practitioner utilize a holistic strategy towards the care of the patient (Barchard et al. 2017).
In the 1990s, the National Health Service (NHS) established Clinical Governance to deal with wastefulness which has turned out to be an unsuccessful management mechanism leading to general low public confidence in the institution (Barchard et al. 2017). The framework guarantee that all providers and individuals can assure the delivery of high-quality care, which can be enhanced upon continually. Besides, clinical governance promises to improve the patient’s safety and facilitate the management of risk. In the same way, national organisations were created including the Care Quality Commission (CQC) and the National Institute for Health and Care Excellence (NICE) were made to sustain the high value of quality and safety (CQC 2020).
Seven pillars which make up the clinical governance include staff management, information & IT, risk management, public and patient experience, clinical effectiveness, audit, training and education (Azami-Aghdashm et al. 2015). The local NHS trust has embraced six themes from these pillars, which encompass leadership, quality improvement, patient focus, staff focus, information focus and Public health. The delivery of a comprehensive and full patient care can be realistically accomplished when all the pillars of clinical governance are achieved (Veenstra et al. 2017). The utilization of the clinical governance coupled with the five whys demonstrated that the misidentification of the patient incident described above was multifactorial which suggest that it was caused by different issues (Azami-Aghdashm et al. 2015). Key elements involved in the misidentification incident which will be analysed included risk management, inadequate teamwork, clinical effectiveness violations, breach of information, WHO checklist, wrist band tangs, staff focus, teamwork, and poor communication (Haxby and Walker 2015).
Misidentification of the patient was partly caused by poor communication. Empirical evident has pointed out that poor communication is likely to cause challenges, especially within the health care sector (Pugel et al. 2015). Serving as a team and successful communication are necessities by the Health and Care Professions Council (HCPC) aiming to sustain the norms of clinical governance which all medical practitioners must follow. In this event, while working as a student of operating department practice (ODP) I realized that adhering to protocol, team working and communication is very important which is the reason the error was noted, and appropriate measures are undertaken to avoid the adverse event. Essentially, Boissy et al. (2016) argued that communication is vital to all the clinical governance pillars. The researchers noted that there is the robust positive association between communication skills of team members of health care and capacity of the patient to adhere to medical recommendations, embrace preventive health traits, and self-manage a long-term condition.
Efficient team working has also been found in empirical evidence to have a substantial impact on the enhancement of patient outcomes and the improvement of patient safety in a way that will minimize human aspects that can contribute to patient safety incidents (Pugel et al. 2015). Research by Rosen et al. (2018) indicated that social factors are bound to lead to typical human mistakes which may substantially affect patient safety. Nonetheless, this may be reduced by embracing good teamwork spirit and efficient communication in all cases involving patients. Reports by the World Health Organization (WHO, 2019), failures of communication are the main cause of different health care linked near misses and incidents. Precisely, in this incident of the misidentified patient, weak communication could have aggravated the incident if the Health Care Assistant did not inform other team members of the mistake. Notably, the top hierarchy among the medical practitioners in the theatre assumed the position of an assertive leader and a decision was made on what, how, and who to report the event. More practically, the Care and Quality Commissions (CQC) advises that it is vital to report ‘never event’, ‘near misses’, and ‘incidents’ which may lead to penalties for the hospital. Reporting events such as ‘near misses’ is an element of risk management which permits providers of medical care services to facilitate learning from mistakes and grow subsequently approaches to enhance patient safety. Incident reporting helps to evade the recurrence of such events which could be damaging and catastrophic (NHS Improvement 2018).
A report by the National Patient Misidentification Report revealed that there is profound and transparent information on the sources and effects of patient misidentification challenges in health care (Ponemon Institute, 2016). Remarkably, the report included responses from over 500 people who are accountable for financial operations and clinical delivery. Results from the report indicated that over 83 per cent of survey participants admitted that misidentifying a patient can contribute to adverse effects or medical errors. Additionally, the main source of patient misidentification is wrong identification of clients at the registration point. The report further explained that patients are misidentified in a ‘normal’ health care organization on a recurrent basis (Ponemon Institute, 2016). Besides, over 68 per cent of research participants noted that such cases occur due to errors, including the inability to ascertain the medical record or patient’s charts. Similarly, approximately 67 per cent of the study participants reported that a query or search leading to duplicate or multiple medical records which contribute to misidentification. Utilizing incorrect documents in the EMR or registration system can contribute to this problem. Finally, the study revealed that nearly £15 million are lost in hospitals per year because of denied claims emerging from the misidentification of patients (Ponemon Institute, 2016).
Rosen et al. (2018) suggested that professional competence is a product of practice efficiency and combined with theoretical knowledge and experience. As a student of operating department practice, I felt personally accountable for the incident that occurred because of my inability to check and confirm the patient and ensure that he was fit and appropriate to go through the surgery. Besides, as a student, I should have looked for the patient with the appropriate document from the online records to ensure that he had accurate information for identification. Fortunately, the incident happened during my placement sessions; hence I was serving within the confines of my scope practice, and efficient teaching and learning as a team is an element of training features of clinical governance.
Conclusion
The Gibbs Reflective Cycle has been utilized to rationalise and scrutinize the critical event that took place in the surgical room because of patient’s misidentification (Gordon et al. eds. 2015). From the critical event, it was evident that the operating department practitioner performed his role of preparing the surgical devices and equipment, assembling of drugs and maintaining good communication with the patient by trying to reduce tension.
However, the critical event occurred because of lack of precise identification mechanisms, registration of patient at the first point, placing of wrist tags and communication between the multidisciplinary team. Essentially, the health care practitioners adhered to the due process to report the event which, which will permit others to learn from the mistakes. At a personal level, the incident was important for me because it shaped my thinking and working when dealing with the patients (Gordon et al. eds. 2015). I have learnt to be more assertive and to strictly comply with protocols if such situations were to emerge in future. However, although I thought I could have done better in the incident by identifying the error earlier, the experience I acquired from the event has improved. For instance, I have learnt that working in the patient’s best interest is the most important thing, particularly by ensuring that I double-check all the information and facts. In fact, this may be the deduction of one of learning experience from a crucial event. Nevertheless, it is the foundation of my development as a practitioner in my career (Gordon et al. eds. 2015). As a result, this experience would be instrumental in influencing my abilities, talents, and skills in my career in surgical rooms, post-operative care units (PUCU) and pre-operative clinics.
Action plan
If such an unfortunate event occurred in the future, I understand what to do. Firstly, I will have a plan to cautiously check the information of the patients who are about to undergo an operation. In this regard, I will have to review the medical records and assess the unique signs that distinguish the patient from others before surgery and also checking demographic information about the patient. Secondly, my practice will encompass being more proactive, especially when I robustly think there is a danger to patient safety. Thirdly, I have learnt to avoid assuming that other professional health workers have worked professionally and to identify all the errors. I changed my perspective on being more cautious and not to entirely trust the actions of my health care partners but to be more observant on the patient’s details. Fourthly, I intend to continue utilizing the Gibbs reflective model (1998) to analyse and evaluate my normal daily activities. In so doing, it would assist me to successfully utilize my clinical skills in the preservation of patient safety and the execution of the principles and values set by the Health and Care Professionals Council (HCPC).
Overall conclusion
Patient identification is the core of successful healthcare since it permits the appropriate care to be given to every patient depending on her or his personal needs. When a patient is scheduled to undergo an operation, accurate medical information is necessary to avoid serious consequences. Such could lead to litigation in court and loss of resources in a court settlement and also the destruction of medical personnel’s character. As a student of ODP, I was involved in preparing the patient for surgery, surgical devices and equipment preparation and improving the patient support prior to the surgery. I was involved in taking him to the theatre, but he was the wrong patient who was not scheduled for surgery. The event taught me to acknowledge that accurate identification of the patient is important at each stage of clinical care to facilitate patient safety. Essentially, I have analysed the incident and demonstrated that identification errors at the ODP could be eliminated by enhancing the utilization of patient identifiers in the hospital system. Additionally, hospitals should formulate and execute efficient patient identification mechanism that accurately identifies patients and retrieves accurate medical record.