The one where the near miss is avoided but other post-op complications arise…..
While Mr Jones, the surgeon, is preparing to operate on the right ankle, Dr Patel moves across to speak with the theatre sister – Sister Higgins – with whom she shares her concerns and who quickly checks the notes.
Seeing that the notes clearly state that it is the left leg Sister Higgins shouts out “STOP! – it’s the wrong leg!” Exclamations of shock and surprise ensue as the team realize that a near miss has just occurred.
Unable to hold back his exasperation, Mr Jones bellows at the nursing team querying who it was that marked the wrong leg. One of the junior nurses runs out of the operating theatre in tears. Annoyed by the setback, Mr Jones commands the team to quickly prepare the left leg for the procedure. While this is happening he turns to Dr Patel and Sister Higgins and loudly berates them angrily asking “Why didn’t you speak up before; you clerked her in didn’t you Dr Patel?…Didn’t you realise it was the wrong leg Sister?” and continues to rant about how poorly the situation could have ended up. Sister Higgins replies that Dr Patel only just drew it to her attention. Dr Patel tries to explain the situation but Mr Jones appears unwilling to listen.
Jane’s left ankle is operated on, and the procedure is completed successfully.
Dr Patel is naturally upset by what happened despite kind words from other colleagues after the operation is over. She feels disappointed with herself for hesitated to speak up earlier, fearful of what could have resulted and is embarrassed by the public reprimanding she received. As a result she finds it difficult to maintain her focus and concentration for the patients she must see on the ward during the afternoon.
Jane is returned to the surgical ward from the post-op recovery ward. Before going to check on Jane, Dr Patel examines another patient who is reported to have a post-op wound infection.
Naturally she wears gloves but in her distracted state, she forgets to wash her hands after.
She reviews Jane and finds that she is complaining about pain in her leg. The bandage on the leg looks rather tight so Dr Patel adjusts the bandage on Jane’s ankle.
Without realising it Dr Patel manages to contaminate Jane’s wound with the bacteria from the previous patient.
Jane stays overnight in the hospital. Later on the afternoon of the following day Dr Patel returns to the surgical ward to perform a quick examination of Jane’s surgical site. Dr Patel discovers that the surgical wound is starting to show evidence of infection and Jane is running a mild temperature.
Jane was scheduled to be discharged, but due to the infection, will require additional treatment and discharge will be delayed. Dr Patel is reaching the end of her shift, and Jane’s care will be handed over to the next F2 coming in.
A briefing about a new post-op wound infection protocol has recently been held in the hospital, which requires doctors to begin antibiotic administration within one hour of the discovery of an infected surgical site.
However, Dr Patel was unable to attend, and is unaware of the new protocol. She makes a note in the patient record to alert the next F2 to the wound infection, with instructions to begin antibiotics and intends to leave a note on the F2 duty list. However, before she can do this, a nurse asks Dr Patel to examine another patient on the ward who has developed post-op chest pain. The infection slips from Dr Patel’s mind, and no record of it is made for the next F2 on duty who will be caring for Jane. Once she reaches the end of her shift, Dr Patel leaves the hospital.
Meanwhile, at the hospital, Dr Lynch has taken over the care of Dr Patel’s patients as the next F2 on-duty.
One of the nurses informs Dr Lynch that Jane’s husband has called to the ward to collect her to go home and just needs a quick discharge letter for the GP. Failing to notice the last entry in her clinical notes, the discharge letter is written and Jane is discharged home.
Questions for Student Comment:
1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
2. What subsequent problems can you identify in Jane’s care and how could they be rectified?