Introduction
Reflection refers to an approach used to comprehend the personal practice process nature, which results in escalated knowledge as well as proper application in healthcare work, which eradicates the chances for medical errors (Walker, 1996). Reflection allows a person to think about an action and through this way, engage in a continuous learning process (Hendricks, Mooney and Berry, 1996: 100). Therefore, reflective practice is the most key source of personal improvement and professional development. As a result, the concept has become popular globally (Price, 2004: 470).
An evidence-based tool of practice applies the best care a patient can afford. The principal goal of evidence-based practice is clinical expert opinion or expertise, caregiver/ patient/ client perspectives (Pattinson, 2011). For the purpose of this assignment, the Gibbs reflective model is vital. A summarized model will offer reflection guidance as structured in the six stages. The stages are; event or description, feeling or thoughts, evaluation, analysis, conclusion, and the action plan. This paper presents a case scenario where the practitioners involved in the care of the patient did not have effective communication, which impacted negatively on the patient. It also emphasizes the need for proper communication in health care.
The Description/ Event
Several years ago, as a senior anesthesia technician was just about to release an ODA for the lunch break, a boy who was approximately 5 years old and a pediatric cardiac patient was undergoing a dental clearance. After the dentist was thorough, the inhalation agent got terminated so as to allow the patient to recover prior to the removal of the endotracheal tube. The long extension set for intravenous use had already been closed as the short procedure was taking place. The boy began breathing again and tried to open his eyes. The reverse drugs were about to be given when the anesthetist requested the ODA to flush the intravenous line using 5ml of normal saline. However, the patient stopped breathing suddenly because of the boule that forced the residual muscle relaxant back into the patient. Consequently, the anesthetist began ventilating the patient, and it took approximately thirty minutes for the patient to recover. The patient did not experience considerable harm.
Feeling
The shock was one of the feelings that overcame me first. The anesthetist was impatient in treating the patient and seemed to be in a hurry (Boud et al, 1985). He ought to have waited before flushing the intravenous line so as to avoid the formation of a boule, which forced the residual muscle relaxant back into the patient. Maybe he wanted to have finished all his duties before releasing the ODA for lunch. Moreover, there seemed to be miscommunication between the ODA and the anesthetist. Both of them should have deep knowledge of the process and, therefore, there should be no errors as was the case (Rolfe, Freshwater and Jasper, 2001). It was extremely sad to see the suffering young boy lying down. I was torn between many negative emotions; sorrow, pity, empathy, and blame on the healthcare professionals (Davies, 2012).
As mandated by healthcare policies and standards, I strongly feel that healthcare professionals should adhere to them to prevent adverse effects on patients (Pattinson, 2011). Professionals ought to realize that there are countless areas where there can be a resultant detrimental impact on the well-being of the patient if there is miscommunication or inadequate communication between providers (Walker, 1996).
In the mentioned occasion, the patient should have taken the residual muscle relaxant out first before flushing the intravenous vein with normal saline (Molyneux, 2001). The anesthetist seemed not to be patient enough. Moreover, the anesthetist went beyond his obligation’s limit by authorizing the ODP to flush without thinking of the repercussions (Schon, 1991). In essence, the anesthetist failed to adhere to the protocol expected during patient management (Mac Suibhne, 2009: 434). Regardless of how long healthcare professionals have been in practice, they should always realize that they are dealing with human life and, therefore, be extremely keen (Mann and Gordon, 2009: 617).
In my reflection, I realized that there are numerous issues that are preventable if there is proper and effective communication within the settings (Schon, 1991). These include drug reactions and interactions, increased care cost and hospitalization time, untimely medications and procedures, and inappropriate treatment. All these can be prevented if professionals adhere to the protocols of effective communication (Asper, 2003: 45). If the anesthetist and ODP were communicating effectively and were aware of the proper guidelines to follow, the patient would have recovered normally from the procedure done.
Evaluation and Analysis
It is imperative for the anesthetist to be aware of his vital role in the patient’s life. Hence, he should have adhered to the set protocol, guidelines, and standards, and ensured effective and timely communication between himself and the ODP. Flushing the IV after muscle relaxation ensures the patient recovers normally (Mann and Gordon, 2009: 617). Healthcare research indicates that approximately eighty percent of all grave medical errors are a result of miscommunication (Price, 2004: 47). It has been noted that when handing over patients to other professionals for specialized procedures, there is always incomplete information handover (Schön, 1991). Moreover, healthcare professionals lack adequate time to discuss the patients’ issues in detail, which results in negative impacts on the patient (Brown et al, 2003: 40).
In my opinion, the anesthetist was not sufficiently accountable and responsible. A medical practitioner who is responsible and accountable enough has a keen interest in a patient’s outcome. In this case, the anesthetist was impatient, which almost led to detrimental effects on the patient. He ought to have been accountable and waited for the muscles to relax before administering the drug. On the same note, the anesthetist and ODP ought to have ensured that proper medication is given to the patient. Price (2004: 40) asserts that this is because giving a patient the wrong medication is unethical and can result in detrimental patient effects.
It is worth noting that ineffective communication goes with other human factors. For instance, there might be differences among the various departments (Molyneux, 2001: 30). When professionals from these departments meet for a procedure, grudges they hold against each other may result in the patient suffering. This is ethically unacceptable and contrary to the patient’s rights (Bolton, 2010). Moreover, it is imperative that professionals go through the guidelines of the procedures they are to perform. This reduces the chances of errors. According to Schön (1991), another ethical measure is to seek the client’s consent.
It is worth noting that many patients suffer as a result of the failure of healthcare professionals to adhere to effective communication. Mostly, healthcare professionals do not dedicate adequate and quality time to patients (Larrivee, 2000: 293). They perform most of the procedures in a hurry, which affects patients negatively (Mann & Gordon, 2009: 620). If the anesthetist was not in a hurry and dedicated to the patient’s result, he would have allowed adequate time before flushing the IV. This would have ensured that the patient responded successfully after the procedure.
Ineffective and inadequate communication has been reported to be the vital contributing factor to inadvertent patient harm and medical errors (Welsh Assembly Government, 2008). It does not only result in emotional and physical inconveniences to all those concerned but also adverse happenings, which are extremely costly. For instance, the resulting cost from medical errors in Victoria’s hospitals is approximately a billion dollars every year (Boud, Keogh & Walker, 1985: 34). It is worth noting that today, healthcare is extremely diverse and complex, and improving communication amidst professionals in healthcare would considerably support safe patient care delivery (Asper, 2003). It is extremely vital that managements in hospitals stimulate action and discussion, as well as raise awareness in regard to the units, divisions, and organizations where more teamwork and improved communication is essential (Brown et al, 2003). Mostly, ineffective communication is particularly the known cause that leads to sentinel events. Ineffective communication which is ambiguous, incomplete, inaccurate, untimely, and where the recipient does not comprehend clearly, increases the results and errors, for poor patient safety (Welsh Assembly Government, 2008).
There exists immense evidence linking poor and ineffective communication between teams in healthcare (Mac Suibhne, 2009: 430). The stated results are extremely negative patient impacts (Brown et al, 2003: 96). For instance, according to America’s Joint Commission, the key cause of more than seventy percent of sentinel occurrences is a communication failure. Moreover, America’s Veterans Affairs Department National Centre for Patient Safety acknowledges that failed communication in healthcare is the chief root foundation of seventy-five percent negative patient impacts (Leitch and Day, 2000: 157).
When the patient sees too many patients, miscommunication may result (Brown et al, 2003: 103). Usually, patients make efforts to ensure the best treatment choices (Larrivee, 2000: 293). However, the treating doctor may be unconcerned about other experts caring for the patient. In most cases, physicians are usually unaware that their patients are being treated for disease complications (Hendricks, Mooney & Berry, 1996: 100). The spectrum of poor communication included services and medication being duplicated, the patient being given more medication than is necessary, and wrong surgery sites (Asper, 2003).
The negative drug interaction is another potential danger. This is mostly because the patient is ignorant of the medication being given and may not identify cases of over medication. Such a situation threatens life and should be prevented at all costs (Boud, Keogh & Walker, 1985: 91). Patients also have a role to play in their health care. They have the right to ask questions and confirm procedures (Davies, 2012: 7).
In order to ensure such a case never repeats among ODPs and anesthetists, the case will be reported to the head of the department. Discussing it will ensure that all professionals handle their patients with extra keenness and that they follow procedures and guidelines well (Ministry of Justice, 2006). Consequently, it will be discussed during the monthly meeting of the department. During the meeting, all health care professionals will be present, including the ODP and anesthetist in mention. Both will be requested to elaborate on what and why it happened. This will be aimed at reviewing their role in every procedure (Leitch and Day, 2000: 154). Moreover, the anesthetist will have to apologize to the family and elaborate on the issue to them. This will ensure accountability. These grave measures will be geared towards ensuring that all patients receive adequate, timely, and proper treatment (McSherry, Pearce and Tingle, 2011).
According to Davies (2012, 10), the main reason for writing and addressing the incident in detail is to prevent and avoid such an occurrence again. It is vital that the ODA enquires and double checks every detail with the anesthetist. Moreover, all drugs and syringes should be labeled to avoid using the wrong ones on the patient. The anesthetist should be the only one who handles them to avoid confusion.
An incident like this happens often in the UK. According to the Health and Care Professions Council (HCPC), such a case happens 109 times annually (Brown et al, 2003: 96). There is, therefore, a need to address issues surrounding it so as to reduce its incidence and prevalence.
Conclusion
In my opinion, failure to dedicate adequate time for patient care and miscommunication are the key causes of this incident. Following the HPC guidelines would have prevented the incident from occurring (Ministry of Justice, 2006). In the mentioned case, an efficient leader who could adhere to the use of a checklist and the structured plan was absent. This would guarantee patient safety before conducting the anesthesia as recommended by WHO.
Recommendation and Action Plan
In the light of this discussion, health care professionals should be trained adequately to ensure their effective communication and accountable participation (McSherry, Pearce and Tingle, 2011). I recommend that a structured documentation checklist, good teamwork, effective communication be made the key targets for a quality improvement plan which ensures patient safety in all departments (Asper, 2003). The majority of hospitals’ managements are unaware of the miscommunication pervasiveness that exists (Davies, 2012: 11). Moreover, miscommunication goes unnoticed in many healthcare settings. Factors that affect the quality of communication are usually ignored, which results in detrimental health impacts on patients (Schön, 1983).
In order to ensure effective communication between healthcare teams, there is the need to consider intercultural communication between staff, the circumstances and content of communication, various discourse modes, presence of resources and opportunities for creating a common body of understanding, and linguistic and cultural distances (Welsh Assembly Government, 2008). The management should ensure strategies where all these are incorporated towards effective communication (Asper, 2003: 34).
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