Home » Episode 4

Episode 4

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.

Ep4 - Tight Bandage

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.

Ep4 - Fever

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.

Ep4 Wound_Prot

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.

Ep2 - Dr Dee

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?

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  52. Anonymous says:

    1. The culture in the operating room is far from ideal. People involved in the procedure clearly feel unconfortable and are afraid of speaking up. It is always important to maintain a culture which allows everyone to raise concerns at any time. The surgeon’s reaction to Dr Patel’s remarks did probably not encourage her to speak up the next time. Instead, knowing the possible consequences, she and her colleagues will think about it twice before sharing concerns the next time. Blaming creates a very toxic and counterproductive atmosphere. Problems and mistakes should be ackled as a team to make sure that something siilar won’t happen in the future.
    2. After the near miss in theatre, some serous mistakes were made: Jane’s doctor was not making sure that no infections was transferred between patients. Being extremely serious when it comes to infection prevention is pivotal if you want to avoid the terrible consequences post-op infections can cause. Secondly, the fact that Dr Patel did not attend the seminar concerning the right handling of early infections had serious consequences. Of course, you are not able to attend every seminar or talk. Nevertheless, it is necessary for every healthcare professional to make sure that he or she is aware of any changes to procedures and guidelines, so that best patient care can be guaranteed at any time. Finally, failed communication between Dr. Patel and the F2-doctor lead to Jane leaving the hopital – even if she should not have! It is important to make sure that patient related information is communicated clearly and effectively between healthcare professionals. While discussing Kevin’s story, we saw what terrible things can happen if clinical communication fails. Making sure that your message actually reaches your colleague is therefore extremely important.

  53. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?

    In this theatre, there is a clear old-school atmosphere of the surgeon is always right, and mistakes end up in a blame game, with the lowest in the hierarchy usually ending up being the scapegoat. The surgeon has created a extremely uncomfortable environment for the multi disciplinary team to work in here. His attitude is very unprofessional as his co-workers don’t feel able to express their professional opinion to him out of fear of him having a go at them. I would like to see the theatre become a place where safety, learning, and improvement are at the forefront of the MDT’s aims. Although I realise the need for there to be clear lead and second during the procedure, I would also like to see less hierarchy outside of the actual surgical procedure, e.g. in MDT discussions and prepping for surgery.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?

    Dr Patel starts to assess Jane without first assessing whether or not she is in a right mind to do so. Dr Patel is very clearly distracted and hurt by previous happenings, and therefore isn’t in the optimum place to be looking after a patient. Due to this, she neglects patient safety by forgetting to wash her hands – a basic level of hygiene missed.
    Dr Patel also
    – didn’t stay up to date on current procedures, again neglecting patient safety and GMC guidelines
    – didn’t finish one job before moving onto the next, and not handing over properly, which resulted in a breach in patient safety, namely Jane being wrongly discharged whilst still needing hospital care for her infection

  54. Anonymous says:

    It appears that the theatre environment is very hostile. The nurses and junior doctors are clearly afraid to speak up about any concerns that they have or any questions they may want to ask. If Dr Patel felt more comfortable and encouraged to speak up, she would have brought up her concern of the wrong knee earlier and then the issue would not have happened in the first place. Any clinical environment should be a safe and comfortable environment for medical staff so they can speak up. The only priority should be patient safety and best possible outcome from the surgery. It appears that due to the toxic behaviour of the surgeon everyone is afraid to speak up. Therefore this will compromise patient care and safety.

    Infection is a serious matter in post-op patients as patients are already weak and delayed treatment can lead to serious harm such as sepsis. Dr Patel should have not left Janes treatment to another doctor. She should know as a doctor the consequence of wound infection regardless of hospital protocol. In addition The second Dr on duty should have spoken to Jane prior to discharge to ensure that she/he has not missed anything.

  55. Anonymous says:

    The Theatre is very unorganised, showing people doing their work independently instead of as a team (when the bandage was removed). People are scared of Mr Jones- this is dangerous as people could choose letting a mistake happen instead of being scolded. The act of questioning a senior can make the senior get defensive if they’re wrong or inflate their ego further if they were correct. Either way these characteristics harm teamworking as working environment is tense and perhaps confrontational rather than open and encouraging.

    The infection could worsen and if Janes immune system is weak other problems may branch from this initial accident by the FY2 doctor. She may be allergic to antibiotics which makes treating infection more difficult. Jane suffers as she receives very poor care and the hand over is also very haphazard which leaves more room for error.

  56. Anonymous says:

    1.A hierarchy exists within the operating theatre with Mr Jones at the top. He views his colleagues as inferior to him and this is shown by the way he treats them. As the surgeon operating, he should have checked to ensure he was operating on the correct site. However, he accepts no responsibility for the near mistake. A blame culture exists and Mr Jones seems angry that the mistake was pointed out, instead of grateful it was identified before any real damage was done. In the operating theatre, there needs to be an open and transparent culture where people feel comfortable talking openly about any concerns or mistakes.
    2.The way Mr Jones responded has negatively impacted Dr Patel and subsequently negatively impacted patient care. Dr Patel is clearly distressed and is not in the right frame of mind to be interacting with patients. Dr Patel needed to take some time to collect herself or speak to someone before going back on to the ward. As she is upset and distracted, more mistakes are made. For example, Dr Patel forgets to wash her hands before examining a patient leading to the infection of Jane’s leg. Visual cues such as signs on the door could be used to remind doctors to wash hands before entering. Dr Patel missed training meaning she was unaware of the hospital’s new protocol to administer antibiotics within the hour. As a result, Jane doesn’t receive antibiotics within the hour. Dr Patel has the responsibility to ensure she keeps her training up to date. She should have made sure she knew about the new protocols from the briefing before treating patients. Dr Patel should have finished Jane’s notes before moving on to another patient. She should have also completed a verbal handover to Dr Lynch before leaving. Both of these mistakes lead to Jane being discharged before her infection has been treated.

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  59. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    There is a detrimental hierarchy in the culture of the operating theatre mirroring the one existing in the medical profession, which causes there to be a lack of trust and communication between the surgical team. Seniority in many doctors has resulted in arrogance, thereby preventing these doctors from further developing in their profession and result in a hostile environment for the patient. Due to the atmosphere created by Mr Jones, Dr Patel was afraid to speak up on a matter concerning the welfare of her patient and was, in turn, rattled when berated by Mr Jones for not speaking up resulting in her forgetting to wash her hands thereby passing an infection onto Jane. By constantly yelling at staff and causing them to feel unable to speak up, Mr Jones is putting his patients in danger of worsening in health. It is vital that there is communication and respect within a team, as this reflects on the care the patient receives. The more questions asked, the more likely doctors and medical staff are to pick up on potential mistakes and provide a solution for them. The culture should be more willing to change and adapt to accommodate to the patient’s needs and ensure that they are receiving the best care available.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Jane has received numerous problems in her care, starting with the A&E doctor’s rash examination resulting in misdiagnosis and a worsened state for Jane. This can always be rectified with more help for the doctor and proper history taking, as well as understanding the patient’s concerns. Secondly, the wrong foot was almost operated on due to an F2 doctor’s fear of a senior surgeon, it was the same F2 doctor who passed on an infection and then failed to follow proper protocol. This was a result of a series of events beginning with the surgeon Mr Jones berating Dr Patel and creating a tense atmosphere in the operation theatre. This lead to Dr Patel letting the events of the operation theatre affect her patients outside, moreover this lead to her failure to wash her hands to prevent the spreading of infection. This can be easily avoided by strict regulations on hygiene and infection control, ensuring that doctors are washing their hands before and after entering a patient’s room to ensure that they are not spreading the infection. Furthermore, unaware of new protocols, Dr Patel decided to leave Jane behind for the other F2 doctor to deal with only to forget to communicate with the doctor to ensure that Jane’s infection is cared for before she is released. This is led to Jane being released with an infection which will further worsen without a doctor to monitor it and provide medication. This can be rectified with better communication between doctors, not only in the form of notes, but also briefing the next shift of doctors and nurses about the patients they were in charge of. Furthermore, to prevent lack of knowledge about new protocols, it should be mandatory to attend post-op wound infection protocol meetings to ensure that everyone in the hospital knows how to deal with an injected patient. In addition, to prevent the release of patients who are not in a proper state to leave the hospital, a check-up should take place before discharging a patient.

  60. Anonymous says:

    1. In the operating theatre, both the doctors and nurses are afraid to speak up with regards to any issues or queries in case they are wrong. Changes need to occur so the optimum care of the patient can be obtained. In order for this to occur, the operating theatre needs to be a place where all staff can be treated equally, without blaming each other and where they can communicate effectively with the patient’s best interest at heart. This would be an optimum environment for junior doctors to learn and develop their skills and feel comfortable asking questions.

    2. The subsequent problems in Jane’s care include the lack of time taken in caring for her. This resulted in a very quick examination by Dr Patel in which she forgot to wash her hands which led to an infection in Jane’s wound. Dr Patel also assumed that the cause of pain was simply due to the bandage being too tight. Other problems include Dr Patel not being aware of the new protocol regarding the administration of antibiotics. Dr Patel forgot to update the notes so that Dr Lynch could be informed about the infection. This would have stopped Dr Lynch discharging Jane wrongly.

  61. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    Clearly Dr Jones doesn’t treat the other members of staff with enough respect, and this has lead to an environment where colleagues are afraid to speak up and double check things, in case of being berated or mocked. This is resulting in poor patient care, and so Dr Jones should be spoken to and his attitude towards other staff members altered, as well as the other members of staff talking to him about how his reactions are unprofessional.
    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Poor hygiene has put Jane’s safety at risk and added complications to her recovery. The communication between the doctors of different shifts is also poor, and instead of leaving notes that can be forgotten or lost, direct communication with the doctors on the subsequent shift should be done.

  62. Anonymous says:

    1. The hierarchical environment is not conducive to patient safety as more junior team members will not feel appreciated or their opinions’ valued. In the best interests of patients and staff, this environment must change by becoming more respectful and less egotistical. All team members should feel empowered to raise concerns/suggestions.
    2. Jane’s care was compromised by Dr Patel not washing her hands and subsequently forgetting to make a note of the infection. However. this is a error due largely to the system as Dr Patel wasn’t aware of the new policy on wound care. Perhaps, future such mistakes could be prevented by ensuring everyone is familiar with new policies, even if they cannot attend the meeting. Additionally, a computerized note system may have enabled Dr Patel to make the note for the next F2 there and then. Dr Lynch also made a mistake by not seeing the latest entry in Jane’s notes. All members of staff can lean from these mistakes.

  63. Anonymous says:

    There is undoubtedly a hierarchal structure within the operating theatre with specialist surgeons on top so an F2 doctor with ambitions of becoming a surgeon would want to be on good terms with the surgeons and take advice from them. Therefore, if an F2 was to speak up they could be dismissed by a more experienced surgeon and subjected to a stern telling off. I would like to see this changed as the operating theatre should be an environment where no one should feel as though they cannot speak up when they see a mistake about to happen but should instead be encouraged to speak up and thanked by their colleagues for avoiding a potential malpractice lawsuit.

    After Dr Patel forgot to wash her hands, Dr Patel noticed the onset of infection to Jane’s leg. She should have been paying closer attention to Jane rather than becoming distracted by another patient. Dr Patel forgetting to inform the next F2 on call about Jane’s possible infective status by writing it in on the F2 duty list is an egregious mistake. Dr Patel should have taken the time to contact the next F2 on call directly to ensure a proper hand-over updating the next F2 on Jane’s status. Dr Patel should have also caught up on the briefing for post- op would infection through discussion with colleagues who were present there.

  64. Anonymous says:

    1)The environment in the surgical ward is hostile in the situation with Jane. There is clear evidence of a lack of teamwork and communication between the surgical team which nearly leads to an error. Dr Patel was undecided whether to speak up about her concerns and this is should not be the case. The multidisciplinary team is at the heart of patient care and communication between the members is essential to ensure a high quality of care is delivered to the patient. A lack of these skills will lead to mistakes which can cause serious harm to patients. Therefore, the atmosphere should be comfortable enough for someone to speak their concerns. In addition, there seems to be an issue regarding a ‘hierarchy.’ Due to Mr Jones being a senior consultant and Dr Padel being an F2 doctor, she doubts her concerns and feels that she knows less than the consultant when this may not be the case. The surgical team should work together on a similar level of authority to make the environment less hostile.
    2)As Dr Padel was distracted following the surgery she forgot to wash her hands when dealing with another patient and this lead to an infection when she performed an examination on Janes leg. She forgot about the hygiene protocol and infection control in the hospital and this resulted in her quality of care to Jane being compromised. Furthermore, when Jane became infected, there was a lack of communication between the two F2 doctors about Janes health status and Jane was discharged with an untreated infection. The multidisciplinary team must maintain high levels of communication and teamwork to ensure that patient safety is not compromised. Dr Padel should try and forget about the situation that occurred during surgery and put it behind her when continuing to practice medicine and treat patients. The importance of hygiene and infection control is highlighted in this event where forgetting to wash your hands can have consequences on other people. To prevent these errors occurring again, there must be strict regulations regarding hygiene and infection control established and should always be a priority when in a healthcare setting. As Dr Padel did not attend the new post-op wound infection protocol she did not realise that doctors should begin antibiotic administration within one hour of discovery of the infected surgical site. However, if she was unable to attend, she should have caught up from a colleague or perhaps attended a different meeting as it is an important change to hospital protocol. Dr Padel should reflect and learn from the mistakes to prevent them occurring in the future.

  65. Anonymous says:

    1. The culture in the operating theatre seems to be very tense and high pressure. The nurses, junior doctors, and F2 doctors are all very nervous and scared, clearly afraid to speak up about any concerns that they have or any questions they may want to ask. If Dr. Patel felt more comfortable and at ease in the OT, she would have brought up her concern of the wrong knee earlier and then the issue would not have come about in the first place. The Operation Theatre should be a safe place and the only priority should be patient safety and best possible outcome from the surgery. Every staff member seems to be on edge and afraid around the surgeon and this hierarchy is bound to lead to issues. Tension and anxiety in the operation theatre will compromise patient care and safety.

    2. Subsequent problems in Jane’s care include the lack of hygiene in Dr. Patel as she failed to wash her hands after treating another patient and before touching Jane. This led to the spread of a bacterial infection to Jane when she was scheduled to be discharged soon. Training on hand washing and hygiene should be mandatory for every member of staff in a hospital, and there should be checks put in place from time to time to ensure the rules are being followed. There was also poor communication about the infection and so it was not taken care of correctly. Jane was subsequently discharged even with an infection in her surgical wound. The message of the infection should have been passed on better, with Dr. Patel ensuring the F2 doctor was made aware of it, and that he/she make the necessary changes in the discharge schedule. The F2 doctor should have also checked carefully if there were any notes to see, and would have then realized that Jane should not be discharged. There should be strict guidelines regarding patient notes and passing on messages when a doctor’s shift finishes.

  66. Anonymous says:

    In the operating theatre there is a sense of hostility. The surgeon Mr Jones exerts dominance over his colleagues therefore he is at fault as he would be accepting partial responsibility of the incidence as lead surgeon, instead he is very self-righteous and places the blame on others which is not a sign of a good leader. The other staff are very submissive at Mr Jones outburst and claims when they should not accept being shouted at for clearing rectifying a near miss that could have had serious consequences. The cultural of the operating theatre would have left the remaining staff feeling lie the cannot speak up when things go wrong as they will lack confidence due to the fear instilled by Mr jones causing nurses to leave crying and Dr Patel to question herself. Mr Jones clearly does not follow to guidelines set out by the GMC one of which is “37 – You must be aware of how your behaviour may influence others within and outside the team”. This theatre is not a productive welcoming environment like it should be.
    Problems noticed in Janes care are as follows:
    • Pain in her leg due to tight bandage
    • Contamination of the wound due to Dr Patel’s failure to be self-aware and washing hands
    • All the staff not being fully educated and up to date on the new protocol for wound care
    • Distraction by Dr Patel by nurses asking to examine another patients with chest pain therefore not finishing the task at hand to leave a note for the next F2 doctor
    • Failure of Dr Lynch to notice the last entry in clinical notes results in early discharge with infection
    These problem may have all been preventable if Dr Patel didn’t leave the theatre very worked up and upset by Mr Jones shouting at her. If the bandage hadn’t have been done so tight by possible anxious nurses then the transfer of infection may have never happened. Dr Patel should have been resilient enough to leave what happened in theatre behind and focus on her new patient but due to distraction she forgot the fundamentals of infection control and forgot to wash her hands. Doctors should be given briefs from meetings they missed and it should be compulsory to be up to date with the newest protocols. The F2 doctor should not be able to start her shift without an informed handover from Dr Patel as this would have allowed the opportunity for missed gaps with patient care to be filled. This could be rectified now If Dr Patel’s remembers she forgot to add a note to extend Janes stay and start antibiotics or it could be rectified by the F2 doing a thorough examination of Jane before she signs the discharge forms, giving her an opportunity to see the infections and treat it.

  67. Anonymous says:

    1 – This is a particular controversial issue that many medical students and junior doctors frequently talk about with one another. In surgery and within a operating theatre, there seems to be a lot of power, control and domination from surgeons like Mr Jones. In addition, there also seems to be a certain degree of subservience from all other members of the team. It was extremely unprofessional for Mr Jones to make rude and cold remarks to the rest of his healthcare team who helped him perform this surgical procedure on Jane. It was clear that he made both Dr Patel and the rest of the healthcare surgical team feel very anxious and apprehensive to be confident enough to speak up and address any concerns they feel might be impacting or may impact patient safety. The way in which Mr Jones goes on and the way he acts in the surgical theatre is not one where good team-working skills are developed, and it is apparent there is not a strong cohesive relationship between all members of this surgical team. This lack of communication and teamwork was a contributor which caused the breakdown in the provision of appropriate healthcare. This not only has negative impacts for future surgical operations where the same members are working together but it is certainly not in the patient’s best interest, which is in direct conflict to the GMC’s guidelines on the Duties of a Good Doctor, where paragraphs 35-37 clearly state:
    35 – You must work collaboratively with colleagues, respecting their skills and contributions.
    36 – You must treat colleagues fairly and with respect.
    37 – You must be aware of how your behaviour may influence others within and outside the team
    Mr Jones has failed to treat his colleagues with a certain degree of respect, and this can further create issues surrounding teamwork and therefore quality of care for patients. This stereotypical culture needs to change because it will therefore indirectly allow for a better quality of care for patients. There should be a culture change where all members of a surgical team should feel confident to voice any concerns without being reprimanded by physicians in more senior roles and perceived amounts of power. Instead of negatively reacting to a near miss, Mr Jones should have thanked Dr Patel for raising and issue he had and encourage him that in the future, he should not be afraid to do so and provide him with constructive criticism to maybe speak a little bit earlier as the operation so nearly begun without him saying anything.

    2 – There have been many subsequent problems in the operating theatre and post-operatively that can be clearly pinpointed regarding Jane’s quality of care and how the factors have led to an inadequate quality of care in her operation and post-operative recovery. The most obvious example is the transfer of the bacterial infection into the wound of Jane’s ankle due to the lack of attention and professionalism of Dr Patel in not washing and sanitising her hands following the examination of a post-op patient with chest pain. Dr Patel, who is an F2, should now be more than aware that it is accepted medical practice that one is required to wash their hands before and after coming into contact with patients. This was an easily avoidable problem in Jane’s care and should not happen. It was also said that Jane’s leg bandage was tied on too tight and has actually caused her to experience a certain amount of discomfort. This is another example of an easily avoidable error in Jane’s treatment where a certain increase in the intricate care of patient’s junior doctors must be aware of when treating patients. Junior doctors should always ask the level of comfort patients are experiencing when any part of their body in dressed in a bandage. If they say it is too tight and uncomfortable, then should do loosen it ensuring you are making the care of the patient your primary concern. The next F2 onto the surgical ward, Dr Lynch, should have definitely examined Jane and had an extensive review of her notes before even considering discharging her, regardless if Jane’s husband has rung and requested to pick her up. If Dr Lynch had of consulted the notes, she would have seen that there was a post-op wound that had been identified and then an appropriate course of action of antibiotic medication could have then been administered as opposed to a discharge.

  68. Anonymous says:

    1. The operating theatre seems like a very unpleasant environment in this situation, where Mr. Jones establishes his authority over everybody else in the theatre. He shows little respect for any of his colleagues and essentially looks down on them. His temper is so intimidating, it causes a nurse to run crying from the theatre. There seems to be frequent shouting taking place which creates a tense atmosphere. It’s clear that Jane’s safety is at risk as they have to quickly prepare the correct leg for examination, with an angry Mr. Jones pressurizing the team. We see little support for Dr. Patel from Sister Higgins as she quickly puts the blame on Dr. Patel for her delay in raising a concern.

    I would like to see better communication skills to be displayed amongst the group, particularly from Mr. Jones, who should really be setting a good example for the others to follow. He shouldn’t be shouting as this is humiliating and upsetting for the person on the receiving end and makes them less inclined to want to help Mr. Jones, with such an unappealing attitude. I think Mr. Jones should show respect to his colleagues and not treat them in such a horrible way. He chooses to blame others which is unpleasant for the junior nurse and Dr. Patel in this situation and he should’ve refrained from doing that.

    2. Dr. Patel made the mistake of forgetting to wash her hands after examining a post-op wound of another patient and proceeding to adjust Jane’s bandage. This caused Jane to develop a wound contaminated with bacteria from that previous patient. This happened as a result of Dr. Patel feeling humiliated and upset following the surgery in the operating theatre. This led to poor concentration and the occurrence of mistakes. If the environment in the theatre had been pleasant, Dr. Patel wouldn’t have experienced such negative, distracting thoughts. As Dr. Patel failed to attend the protocol meeting, she was unaware of the important information discussed at it, which is serious and she certainly should have made it her duty to attend it or at least find out about the discussion. Dr. Patel displays bad practice as she makes another mistake of forgetting to put the note in the F2 duty list, a critical thing to do. It’s so important that information is provided to the doctor taking over for the next shift. Dr. Lynch also displays negligence as Jane’s last entry in the clinical notes is ignored and Jane is wrongly discharged from hospital. Overall, we see the importance of concentration and good clinical practice in ensuring patient safety.

  69. Anonymous says:

    1.
    The culture in the operating theatre is one of fear. Mr Jones’s temper and rage unsettles the whole team, even reducing a junior nurse to tears. This would make the team uneasy and more unsure of their actions going forward. He rants about how poorly the situation could have ended up. Sister Higgins and Dr Patel are both qualified in their fields and would be fully aware of the implications of going through with the operation on the wrong leg. This patronising tone would impact their confidence in their own clinical practice, despite making the correct decision to make Mr Jones aware of the error.
    There is a culture of blame. Mr Jones’s immediate reaction is to verbally attack the nursing team, despite not knowing the true cause of the leg being marked incorrectly. This blame culture is further perpetuated by Sister Higgins, who shifts blame to Dr Patel when Mr Jones’s anger is directed at her. She is not willing to accept her own mistakes, and Mr Jones is guilty of this as well. As the head surgeon he should have thoroughly checked which leg was to be operated on and been fully aware of this going into theatre. Not admitting his mistake gives him more power in the operating room, which in turn increases the difficulty of speaking up against him.
    There was no praise for catching the mistake in time, which promotes a negative environment further deterring staff from speaking up in front of Mr Jones if such a situation repeats itself.
    Mr Jones was unwilling to listen to Dr Patel’s explanation as he is more concerned about progressing with the surgery. It is only human to make mistakes, and they are acceptable as long as they are put right, and lessons can be learned from them. If Mr Jones refuses to reflect on this incident, there is no way to guarantee it will not happen again as preventative measures cannot be put in place.

    I would like to see a more open surgical environment, where everyone’s views are able to be expressed without fear of judgement or scolding. Mr Jones’s attitude needs to change, as he should not make any of the staff frightened or uneasy when they are there to help him and keep him right. I also think the operating team should meet afterwards and discuss the pre-surgery events and come to the root cause of the issue. This will go a long way in improving patient safety, if mistakes can be identified, targeted and eliminated.

    2.
    There are a few noticeable issues with the way Jane was cared for after her operation. Dr Patel was upset and distressed after the ordeal with Mr Jones. She should have taken some time to compose herself before attending to patients. It is good practice for a doctor to do a quick self-assessment; are they healthy, tired, hungry, in a good state of mind? This helps identify factors that might impact their ability to carry out clinical tasks and therefore increases patient safety. She should remind herself that she prevented a grave mistake from occurring, which would hopefully increase her confidence. Again, a more positive working environment would reinforce this.
    Dr Patel made the error of not washing her hands after inspecting an infected wound. This should be engrained in all doctors for the safety of patients as well as their own. Perhaps more training, or more stringent health and safety spot checks, need to be carried out to reinforce this.
    Jane was not seen to until the late afternoon of the next day. Whilst the wards are likely busy with staff shortages, patients just out of operations should be made a high priority. If Jane was seen to earlier, the infection could have been detected and treated sooner.
    Being unaware of protocols can be very dangerous. Dr Patel should have made an effort to attend the meeting, or at least researched and familiarised herself with the new guidelines. Better hospital-staff communication is necessary to ensure all healthcare workers are up to date with changes in hospital rules.
    Although the hospital ward was surely busy and the nurse was asking Dr Patel to see to another patient, she should have ensured a note was left for the next F2 doctor. Jane’s care should not be compromised, especially if it would take a short amount of time to explain the situation to the nurse and leave the message. Better yet, Dr Patel should have stayed on until the F2 doctor came to take over. Despite probably being anxious to get home after her tough day with Mr Jones, it would be more beneficial to stay and do a verbal handover, making Dr Lynch aware of Jane’s infection and her notes. Dr Patel should have also alerted nursing staff to the new infection, so they could monitor and attend to Jane properly. It would mean they could intervene if they noticed Dr Lynch had not been made aware of Jane’s condition.
    There were also a few errors on Dr Lynch’s part. She should thoroughly check patient notes. However, if Dr Patel’s note was small or perhaps written on a loose page that could easily fall out, the information about delivering antibiotics could be overlooked. Dr Lynch should not have been so hasty in discharging Jane. It would have been better to give her a proper final check over before allowing her to leave the hospital.

  70. Anonymous says:

    The culture in the operating theatre is one that leads to junior doctors and nurses not wanting to speak up about or question any potential mistakes they think might be occurring, for fear of being reprimanded. This is detrimental to patient safety because if other members of the team are too scared to question the lead surgeon this could lead to mistakes, which could have been avoided. Furthermore, the team’s fear of Mr Jones leads to them blaming one another because they don’t want to be shouted at. This could prevent team members from acknowledging their own role in a near miss and stops them learning what mistakes they made and what they need to do in future to prevent it happening again. The culture in the operating should be one where Mr Jones is willing to listen to concerns from other members of the team and without becoming frustrated and angry. It should also be a culture where all members of the team are encourage to reflect on mistakes that are made and their potential role in them, including Mr Jones himself.

    The following problem in Jane’s care was Dr Patel forgetting to wash her hands between patients due to her distracted state, a distracted and stressed doctor will not be working to a high level of performance and is more likely to make mistakes. If Dr Patel had taken some time after the incident to talk to someone or reflect on what had happened she may have been better able to focus on her subsequent patients and would not have forgotten to wash her hand before attending to Jane. Another problem was Dr Patel’s lack of knowledge regarding the new post-op wound infection protocol. Despite being unable to attend the briefing Dr Patel should have sought out the information that was given in the briefing so that she made herself “familiar with guidelines and developments” that have an impact on her work, as is outlined in Good Medical Practice. There was also a problem in the continuity of Jane’s care between Dr Patel and Dr Lynch. Dr Patel should have tried to talk to Dr Lynch in person to ensure she shared “all relevant information with colleagues involved in your patients’ care” as is stated should be done before going off duty in Good Medical Practice. If this was not achievable Dr Patel could also have mentioned it to one of the nurses on the ward so at least there was someone else who knew about it so she wasn’t just relying on Dr Lynch reading a note which could quite easily be missed. A further problem was Dr Lynch not thoroughly reading Jane’s notes before writing the discharge letter.

  71. Anonymous says:

    Within the operating theatre it is evident that the environment is quite tense and hostile. This is probably a result of the culture of blame shown during Jane’s operation. This is evidenced by Mr Jones “bellowing” at the nursing team and “berating” sister Higgins and Dr Patel. It was also Mr Jones’ responsibility to look over the patients notes before the operation. The fact that he is not taking any of the accountability for the near miss would suggest that he believes there is a hierarchy present in the operating theatre. This could be his justification for his attitude towards the other members of the multi-disciplinary team as he may feel that he has authority over them in some way. When the junior doctor leaves the operating theatre in tears the reaction of Mr Jones to show anger and frustration shows a clear lack of empathy. Also, his reaction towards Dr Patel is likely to result in her being less likely to raise concerns in future. It also puts the patients that Dr Patel treats for the rest of the day in danger as she is likely to be distracted with what has happened in the operating theatre earlier in the day. This can be seen to be the case through the contamination of Jane’s wound by Dr Patel later in the day. The culture in the operating theatre should be one of equality where everyone feels that they can voice their concerns and that their opinion is valued by the other members of the team.
    One mistake in Jane’s subsequent care is Dr Patel forgetting to wash her hands which leads to contamination of the wound on Jane’s leg. Dr Patel being unaware of the new protocol in place in reference to post-op wound infection was an issue. Thus, there should have been rules in place to ensure all staff are kept up to date with the latest changes in protocol if they cannot attend meetings where this protocol is explained. In order to ensure that Jane’s infection could be dealt with by antibiotics Dr Lynch should have been more attentive to Jane’s patient notes. Also, Dr Patel should have taken the time to write a quick note for Dr Lynch to ensure the antibiotics were given to Jane. Dr Patel could have alerted other members of staff that Jane needed antibiotics so that there would be someone on the ward that knew Jane needed the antibiotics. One other problem was the lack of communication to Jane. If Jane was made aware that she needed antibiotics for an infection it is likely she would have told Dr Lynch about this and he would have checked her notes again.

  72. Anonymous says:

    1. The culture in the operating room imposes fear upon members of the team in relation to speaking out if they have concerns or have the need to raise issues. This culture needs to change in order to encourage members to raise important issues ensuring that everyone is mutually respected. Rather than blaming his colleagues Mr Jones needs to admit to his mistakes and a root cause analysis should be undertaken to avoid future issues like this occurring. Finally, the communication within the surgical team is of a very poor standard-something that needs to change if patients are to receive a good standard of care.
    2. One of the subsequent problems in Jane’s care is that she suffers a healthcare associated infection. This is due to Dr Patel’s failure in washing her hands in between seeing patients. This could be improved by Dr Patel taking more due care and attention to proper hygiene protocol to prevent the spread of infection. This could be achieved by taking note of the 7 step posters that are displayed throughout the hospital. There was also poor communication on the part of Dr Patel in that she did not pass on the information to the F2 doctor in relation to post-operative care. In addition, the fact that Dr Patel missed the talk on antibiotic administration is again putting patient safety at risk. In order to prevent this from happening again Dr Patel could have attended the course on another date or in another location in order to catch up.

  73. Anonymous says:

    1. In the operating theatre, there seems to be a culture of domination from Mr Jones and subordination from all other members of the team. Mr Jones’ cold and forthright attitude is making the other members of staff nervous to voice their opinion. The way in which he acts in theatre is damaging for the relationships between members of staff, causing a break down in communication and teamwork. This can be highly dangerous, as demonstrated from this episode; it can lead to inappropriate treatment of patients which can lead to, at best, a lack of faith in the health care system from the patient if not worse. This culture needs to change in order to provide the best possible service for the patients. Dr Patel and the ward sisters should be able to freely voice their opinion without fear of being reprimanded. In realising that the wrong leg was about to be operated on, they should be commended for noticing and being able to avert the situation. However, this simple error shouldn’t have happened, and their should have been measures in place to ensure this. This can be accomplished by reflecting on the mistakes that have led up to that point, yet Mr Jones’ hostile behaviour makes this very difficult.
    2. There have been many problems following in the operating theatre regarding Jane’s care:
    • Transfer of infection due to lack of attention and not sanitising hands between patients (Dr Patel). You are required to wash hands before and after every patient contact.
    • Tying on Jane’s leg bandage too tight which lead her to become uncomfortable. Specific due care and attention needs to be made when treating patients.
    • Dr Patel not attending the briefing about the infection protocol which led to Dr Patel not treating her right away. All staff need to be informed if they are unable to make certain briefings or talks.
    • Planning to write a note for the next F2. Dr Patel should instead pass on the message verbally if possible.
    • Dr Lynch should have examined Jane before discharging her. She would have noticed the notes and hence her infection.

  74. Anonymous says:

    in the operating theatre there is a fear of speaking up and raising concerns. This leads to a breakdown in teamwork and communication resulting in a dangerous environment. Mr Jones seems to hold himself superiorly to the rest of the theatre team and uses humiliation as a strategy to prevent problems within the surgery, he also passes the blame to anyone other than himself and I think this is part of the problem as he is not willing to own up the others are scared to query any issues.

    other problems in Janes care are that notes of her change in state and need to stay in hospital longer due to her developing an infection should have been recorded straight away, the new doctor on the ward should have also thoroughly read the notes before discharge. although Dr Patel was distressed after her confrontation with Mr Jones she should have taken a while to reflect on it and calm down before letting it affect her work. Simple things like washing her hands and keeping up to date with new protocols could have prevented these mistakes

  75. Anonymous says:

    1. The culture in the operating room means that members of the team are scared to speak if they have concerns or need to raise issues. This culture needs to change in order to allow all members are encouraged to raise important issues and everyone is mutually respected. Issues that are raised or realised should be dealt in a manner that doesn’t humiliate members of the team as this may prevent them raising them in the future.
    2. There are numerous faults in Jane’s subsequent care such as lack of investigation into what is causing the pain in the leg, instead the bandage is just loosened. Dr Patel forgets to wash her hands which results in Jane’s safety becoming compromised and an infection resulting. This infection is then not noted in Jane’s notes nor is anything done about it which leads to Jane’s discharge from hospital. These instances could be avoided if more time was given to the patient and ensuring that any protocols or meetings that have been missed are caught up on as it is a doctor’s duty to keep update with medical knowledge and protocols.

  76. Anonymous says:

    1. The culture of the operating theatre seems to be one in which Mr Jones acts superior to the rest of the operating team, evident in his shouting at the nursing team, his ‘command’ to have the right leg prepared and his public berating of Dr. Patel and Sister Higgins. This is a dangerous attitude to have, as it leads to a breakdown in teamwork and communication, putting patient safety at risk as a result. This is clear in Dr. Patel’s hesitation to even speak up over the mistake being made. This must change if future operations are to be successful. Each team member must feel valued and empowered to speak up about their concerns. Another feature of the operating theatre’s culture is the apparent attitude to get the job done quickly, rather than done right. I think this is demonstrated in Mr Jones’ quickness to blame Dr. Patel and Sister Higgins for the near mistake, rather than thank them for pointing it out or seriously finding out how the mistake nearly occurred. When Dr. Patel tried to explain the situation, he ‘didn’t listen’. Mr Jones is showing a lack of reflection on the event and as a result, similar mistakes are likely to happen in the future. Again, this must change. Mr Jones needs to consider how the mistake nearly happened through having a private discussion with Dr. Patel, Sister Higgins and any other team members that may have been involved. Once he has discovered the cause, action must be taken based off these findings.

    2. The next problem to occur in Jane’s care is the contamination of Jane’s wound. This could be rectified simply by Dr. Patel washing her hands, but the root of the problem is Dr. Patel’s distracted state causing her to forget to wash her hands. Therefore, it may have been a good idea for Dr. Patel to take a short moment to collect her thoughts, speak to someone following the incident in the operating theatre and calm down in general. The next problem to occur is Jane’s discharge when she needed to stay and begin additional treatment. The cause of this problem seems to be Dr. Patel being unaware of new post-op wound infection protocol recently introduced. This could be rectified by the hospital taking note of staff who were absent from the briefing on this new protocol and sending them an email. The email could notify there has been new protocol introduced and arrange a second briefing which can be attended.

  77. Anonymous says:

    1. The current culture in the operating theatre is not how it should be. All staff in the theatre, regardless of where they are ranked should be able to speak up without the fear of being shouted at. At the end of the day Dr Patel and Sister Higgins only spoke up because they were protecting patient safety, which is more than can be said for Mr Jones who was about to operate on the wrong foot. In addition, those who speak up and prevent mistakes should be praised, as they have prevented a possible disastrous situation. Dr Patel and Sister Higgins humiliation in front of the rest of their team would have deterred them from speaking up in future. This is not how it should be. The operating theatre should be a level playing field in which they can raise any issues to those above and below them, knowing that there wont be any judgement or repercussions. At the end of the day, they are all striving for a common goal – getting the patient operated on and away. Mr Jones should actually be thanking Dr Patel and Sister Higgins for preventing him making a mistake which could have got him in a lot of trouble.

    2. Reading this story, I can see a lot of errors in Jane’s care that could have easily been avoided. Although Dr Patel is understandably upset at her humiliation, she should not let this affect her quality of care to her patients. One of the easiest ways to stop the spread of infection is to clean your hands. This is a key key concept in halting the spread of disease and infection and really quite easy to do. Although she did put on her gloves, this isn’t quite enough to stop the spread of infection and as we can see, it has had awful consequences. As a doctor, Dr Patel should understand that although her shift had perhaps ended, she needs to make instructions clear for the next doctor coming on as she could be setting up a chain reaction that would be breaching patient safety. As Dr Patel wasn’t aware of the post-operation wound infection protocol, she shouldn’t have been handling any post operation wound cases until she had informed herself as to what she had missed. I do understand that Dr Patel had left a note in the patients record for the next F2 doctor to see, however, the new protocol requires antibiotics to be given to the patient within one hour of the discovery of an infected surgical site. Whats to say that Jane is at the bottom of the list on the F2 doctor that is coming on, therefore she wouldn’t be seen within the required hour. The thought of leaving a note on the F2 duty list was good, however, she forgot to do this therefore was ineffective. As soon as this infection was realised, the patient’s notes should have been updated to instruct her not to be discharged until her infection was under control, and she had been given antibiotics. Poor management of Jane’s wound on Dr Patel’s behalf has resulted in her being discharged, with an infected wound which will probably get worse as she hasn’t been given the right treatment.

  78. Anonymous says:

    1. The current culture in the operating theatre is not how it should be. All staff in the theatre, regardless of where they are ranked should be able to speak up without the fear of being shouted at. At the end of the day Dr Patel and Sister Higgins only spoke up because they were protecting patient safety, which is more than can be said for Mr Jones who was about to operate on the wrong foot. in addition, those who speak up and prevent mistakes should be praised, as they have prevented a possible disastrous situation. Dr Patel and Sister Higgins humiliation in front of the rest of their team would have deterred them from speaking up in future. This is now how it should be. The operating theatre should be a level playing field in which they can raise any issues to those above and below them, knowing that there wont be any judgement or repercussions. At the end of the day, they are all striving for a common goal – getting the patient operated on and away. Mr Jones should actually be thanking Dr Patel and Sister Higgins for preventing him making a mistake which could have got him in a lot of trouble.

    2. Reading this story, I can see a lot of errors in Jane’s care that could have easily been avoided. Although Dr Patel is understandably upset at her humiliation, she should not let this affect her quality of care to her patients. One of the easiest ways to stop the spread of infection is to clean your hands. This is a key key concept in halting the spread of disease and infection and really quite easy to do. Although she did put on her gloves, this isn’t quite enough to stop the spread of infection and as we can see, it has had awful consequences. As a doctor, Dr Patel should understand that although her shift had perhaps ended, she needs to make instructions clear for the next doctor coming on as she could be setting up a chain reaction that would be breaching patient safety. As Dr Patel wasn’t are of the post-operation wound infection protocol, she shouldn’t have been handling any post operation wound cases until she had informed herself as to what she had missed. I do understand that Dr Patel had left a note in the patients record for the next F2 doctor to see however, the new protocol requires antibiotics to be given to the patient within one hour of the discovery of an infected surgical site. Whats to say that Jane is at the bottom of the list on the F2 doctor that is coming in, therefore she wouldnt be seen within the required hour. The thought of leaving a note on the F2

  79. Anonymous says:

    1) It is clear that bullying takes place frequently in the operating theatre. Mr Jones, the surgeon, seems to be the perpetrator while the nurses and more junior doctors seem to be the victims of the bullying. The fact that Dr. Patel felt very hesitant to speak up about the fact that Mr. Jones was about to operate on the wrong leg for fear that she would be shouted at shows the extent to bullying that is actually taking place – an operation nearly had an operation on the wrong ankle because the surgeon struck so much fear into the junior doctor that she was too scared to speak up. The fact that she and Sister Higgins were also reprimanded after the near miss had been avoided shows that there is no gratitude in teamwork but only the attitude that everything that could go wrong is someone else’s fault as opposed to the surgeon’s. It would be better if there as a more peaceful environment where everyone valued their team members and looked out for each other without the fear of getting shouted at for speaking up.

    2) After the near miss incident, other problems that occurred in Jane’s care were that Dr. Patel forgot to wash her hands after examining a patient with a post op wound infection and before examining Jane and therefore the infection was passed on to Jane. It was not noted in Jane’s notes that she had developed a wound infection and therefore the next F2 doctor on shift did not know. Dr. Lynch was also careless in reading Jane’s chart and so had so had missed the last entry and sent her home. These problems could be rectified by Dr. Patel taking a few minutes to compose herself after being reprimanded before going and seeing more patients so that she is not distracted and so does not fail to carry out basic tasks like hand washing. She should also try to ensure that she finishes making important notes for the next doctor to see before she goes and attends to patients that the nurses are asking her to see, so that vital notes are not missed by the next doctor on duty. Dr. Lynch should also try to ensure that she reads a patient’s chart carefully before discharging them to ensure that nothing has happened that would contradict the original time for discharge.

  80. Anonymous says:

    1. There is a clear hierarchy whereby health care professionals at the bottom of the hierarchy are afraid to voice ou due to the ill behavior of the ones who are at top of the hierarchy. This culture should be amended so that all health care professionals have the right to voice out any concerns especially with those which put patients’ safety at stake. However, there’s a certain way whereby a junior member of staff should challenge a senior member of staff. Junior members of staff should always convey his or her concerns in a respectful manner without raising his or her voice. On the other hand, the senior member who is being challenged should not criticized the junior member for being able to point out the mistakes.

    2. Due to being criticized by Mr. Jones, Dr. Patel could not focus fully on her patients’ care. One of them is that she forgot to wash her hands after examining a patient and proceed to access Jane’s post-surgical wound. Hand hygiene is the first line of defense in which the spread of infection can be avoided. Dr. Patel’s forgetfulness had lead to infection in Jane’s post-surgical wound. Posters and signs should be stuck agist the wall near the bedside of the patient so that health care professionals are always reminded to wash their hands before examining any patient. Moreover, Dr. Patel should have written down the important notes in the patient record no matter how busy she was so that the next F2 is informed and able to carry ou the relevant procedure. Dr. Patel’s mistake of not writing down the relevant instructions in the patient record might cause huge harm to Jane’s condition whereby an undiscovered infection might lead to severe complications or even death when Jane was able to be discharged instead of staying back to receive the relevant procedure to treat the infection.

  81. Anonymous says:

    1. Within the operating theatre there is a very apparent bullying culture. Both Dr Patel and the theatre nurses are terrified to speak to the senior surgeon Mr Jones even when the patient’s safety is at risk. Dr Jones behaviour is completely inappropriate as he is ignorant, short tempered and very quick to blame others for his mistakes. I would like to see the blame culture within the theatre change. Rather than blaming his colleagues Mr Jones needs to admit to his mistakes and a root cause analysis should be undertaken to prevent the issue arising ever again. Furthermore the communication within the surgical team is of a very poor standard, something that needs to change if patient’s are to receive good standards of care

    2. Following the surgery Dr Patel should have taken a short break to calm down and mentally prepare herself before seeing patients. Due to her emotional state Dr Patel did not follow adequate hand hygiene standards, and by not washing her hands after examining a surgical wound infection, transferred that same infection to Jane. Regardless of whether or not Dr Patel was able to attend the meeting on antibiotic prescriptions after the discovery of surgical wound infections, she has a responsibility to keep up to date with such information, according to the Good Medical Practice. Doctors should also ensure that their notes are comprehensive and accurate to ensure a complete handover is completed. Had this been done Dr Lynch would not have discharged Jane early.

  82. Anonymous says:

    1. The culture in the operating theatre appears to be a place of fear and it is evident there is a hierarchy present. It seems as if Mr Jones feels he is superior to the other members of the team, which explains the lack of communication between staff. When the issue was raised, Mr Jones was more concerned about who was to blame rather than correcting the problem and ensuring this didn’t happen again, he felt the need to reinforce his authority by belittling both Dr Patel and Sister Higgins which resulted in a junior nurse leaving the theatre in tears. In future I would hope to see effective communication between the team and an environment in which question and concerns can be raised without fear of humiliation.

    2. There is evidence of lack of communication between Dr Patel and the F2 doctor which has resulted from Dr Patel being distracted. This could be avoided by Dr Patel had she had taken a few extra minutes to finish Jane’s notes before moving onto other patients and had she realised that she hadn’t finished the notes, contacted the F2 doctor immediately to bring this to their attention. As a result of Dr Patel not being informed of the latest hospital protocol it has put a patient at great risk, when she missed the briefing she should of caught up as soon as possible before continuing to practice. By Dr Patel not following through on the hygiene protocol it is possible that this has resulted in Janes infection, Dr Patel should be conscience of taking proper hygiene precautions in-between examining patients to avoid this happening in the future.

  83. Anonymous says:

    1. In the operating theatre there is no true cooperation between the team members. Doctors and nurses should feel that they can always raise their concerns without a fear of being disregarded by other member of the team. Mr Jones’s behaviour was inappropriate, he should not have started blaming others especially while still in the operating theatre. The situation should have been clearly analysed in order to ensure that a similar mistake will not be made again. However, this should have been in a form of discussion between all of the team members rather than Mr Jones’s harsh comments towards the nurses and Dr Patel.
    2. The first issue regarding Jane’s post-op care was infection of her wound which resulted from Dr Patel’s inattention. Dr Patel had a right to feel stressed after the event in the operating ward. Nevertheless, she should not have allowed that to affect her performance especially when it comes to meeting the basic yet significant safety and hygiene standards. Moreover, Dr Patel did not administer the antibiotics according to the new protocol as she did not know about the recent change. Regardless of the fact that she was not able to attend the briefing, she should have been informed about a new post-op wound infection protocol. This situation may highlight that one of the main issues in the hospital is poor communication that leads to serious consequences for patients. Finally, Jane should not have been discharged with an unhealed infection. This could have been prevented if Dr Patel’s notes were careful and comprehensive. Furthermore, Dr Lynch should have examined Jane before discharging her. Having done so, she would notice the infection even if it was not included in the notes.

  84. Anonymous says:

    The culture in the operating theatre is definitely one of hostility and fear following the incident. Mr Jones being annoyed and yelling at the staff created a lot of anxiety for the staff, resulting in one of them crying. There is also a culture of blame apparent in the theatre, as Mr Jones is keen to blame both Dr. Patel and the nursing staff for the error instead of considering that it was his own actions and want to prepare quickly for the surgery that contributed to the near miss. I would like to see a number of things change in the operating theatre, beginning with a clear pause before the procedure begins for the team in the theatre to ask any questions and raise any issues, so that a near miss does not occur again. I would also hope that the operating theatre could become a place of teamwork rather than fear, as the public humiliation and blaming that occurred in the situation distracted the staff and had further ramifications for patient safety. I would also like to see greater levels of respect for the staff in the theatre, as all have an important part to play in the operation and should be treated well by other members of the team.

    There are further issues in Jane’s care, mainly caused by carelessness and Dr. Patel’s distracted state.
    -There is a transfer of bacteria that causes an infection when Dr Patel forgets to wash her hands. This should be an avoidable by proper hand hygiene, which did not occur because her mind was still on the events of the operation. If the operating theatre culture changed, this could limit the mistakes later caused by Dr Patel, and she also has to be resilient and out her own embarrassment out of her mind to best care for patients.
    -Dr Patel does not record the infection in Jane’s notes as she is distracted by another task. This puts Jane’s health in further difficulty and could be rectified by Dr Patel making a note as she goes along with her work, instead of hoping to remember later.
    – THe infection is also poorly dealt with as Dr. Patel is unaware of the new infection procedures, due to missed training. This mistake can be fixed if she had found out from a colleague what she had missed in the training session if she could not attend, or also fixed if she had been in attendance at a workshop which would benefit her clinical learning.
    – Dr Lynch is also at fault in the failings of Jane’s care, as she does not read the latest notes or examine Jane herself before discharge. Jane also could have played a larger role in her own care if the 2 F2 Doctors had spoken to Jane about the potential infection, lowing her to better understand her care and the risks about her discharge.

  85. Anonymous says:

    The culture in the operating theatre in this case is one in which less experienced colleagues and nursing staff feel intimidated by the domineering surgeon. This is not acceptable and will cause a greater amount of errors compared to an operating theatre with a more open environment in which all staff feel comfortable in raising their concerns. In this case the justified fear of the staff could have caused the surgeon to operate on the wrong half of the body to be operated on. To say their nervousness is without reason is wrong and so the root of this must be changed.
    Jane’s care after the operating theatre was lackadaisical. Her lack of attendance at the class laying out new protocol is a problem and her awareness of this knowledge could have saw Jane’s infection treated. She should have found out any new protocol presented. The hospital could have also ran numerous classes on this or staff who were unavailable at that time. Her lack of hygiene is problematic and so she must take more in her examination preparation.

  86. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    Surgeon is king (or sometimes god) complex means that they feel they can do no wrong blame others for problems but accept all the praise for a success. If they are in charge it means that they take responsibility for everyhing happening in their team but also respect everyones opinion. They should observe all of the procedures and also develop a more welcoming environment so that everyone feels they can speak up.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    This infection has been caused by her hospital expossure, it has also been allowed to slip past treatment and can impact her recovery dramatically. In the long run it could cost her her leg, or life in the worst case scenario. It will also cost the hospital more time and work to solve the issue afterwards. She should begin treatment immediately to combat this infection. Hand hygiene should be followed at all times and proper checks performed before discharge.

  87. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    The current culture in the operating theatre is one of fear of speaking up and challenging someone in a higher position. Dr Patel and the nurses do not feel that Mr Jones is approachable and when they do he berates them for not speaking up sooner. For this case in particular the surgical site should have been checked again from the patient’s notes just before surgery no matter what. Everyone should feel that they have an equal voice in the operating room. Everyone should try to be approachable.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Dr Patel failed to wash her hands between seeing patients which has resulted in an unnecessary infection for Jane. Jane has been discharged with a surgical wound that is infected. This could fester while at home resulting in a further hospital visit and Jane’s trust in the profession could decrease even further as she would expect the doctor to flag the infection up before she was discharged. Dr Patel should have dealt with the infection immediately or notified one of the staff before leaving. It should have been written more clearly on her notes as something that needed to be addressed.

  88. Anonymous says:

    The environment in the operating theatre seems toxic, with the surgeon scaring his colleagues and appearing to act from a position of high authority. Patient safety can be risked with this environment, and a more inclusive approach with everyone feeling as if they can voice their opinion is much safer.

    Dr Patel’s failure to wash her hands, despite being under stress, is an issue that she must correct to ensure future patient safety. In addition, a lack of communication between Dr Patel and the Doctor on the following shift has resulted in a premature discharge, and the time must be found in the future to make correct note of this infection.

  89. Anonymous says:

    1.
    There seems to be a tense, slightly hostile working environment within the operating theatre. Mr Jones treats the other staff with disrespect and believes he can berate and talk down to his colleagues. Due to his behaviour, his colleagues do not feel able to be open and transparent. I would like the operating theatre to become a more open environment, where colleagues work together and good communication is encouraged. It would also be great if all staff were respected and treated equally,

    2.
    Jane’s care has suffered in several ways. Dr Patel failed to examine her correctly and failed to investigate the source of her pain. Also, proper hygiene regulations were not followed and subsequently, Jane’s health has began to deteriorate. Dr Patel could have rectified these issues by correctly washing her hands before examining Jane and also taking her time, ensuring that Jane’s condition was thoroughly reviewed. Even though she was in a rush and under time pressures, Jane’s care should have been placed first and her notes should have been updated accordingly instead of leaving this task to the next doctor. Doctors should also have been more aware of any new protocols introduced in the hospital.

  90. Anonymous says:

    1. The operating theatre is presented to us as an unhappy environment where Mr Jones undermines other theatre staff. His approach could be interpreted as bullying and dominating. There seems to be a sense that Mr Jones sees himself as superior among his colleagues and not responsible for the error. His reaction was to immediately blame a specific individual, rather than accept his role and thank the team for raising their concerns. Additionally, Mr Jones did not listen to any explanation from Dr Patel but instead opted to “publicly reprimand” his junior doctor. Ideally I would envisage that healthcare teams create an non-blame culture where errors are reflected upon in a systemic way with root cause analysis. Constructive outcomes from reflections would be implemented and welcomed by all team members. If personal feedback is required it would be delivered in an appropriate setting, after time for reflection and presented with lessons learnt and future support.

    2. The problems in Jane’s care included: Dr Patel missing two opportunities to wash hands, Dr Patel was unaware of the very new protocol, the realities of a busy F2 job led to Jane’s antibiotic requirements not being the highest clinical priority. I feel it is important to recognise that Dr Patel was prioritizing her tasks correctly based on clinical need – if we are in the same position as Foundation Year doctors, we will understandably attend the patient with chest-pain as an urgent priority. Sadly human error resulted in a poor handover. These are part and parcel of any real-life busy shift as a foundation doctor. Additionally, Dr Lynch should have reviewed the most recent entries to Jane’s medical notes before issuing a discharge letter. However, I can understand how the huge pressure on a foundation doctor can lead to human error. Dr Lynch and Dr Patel did not intend to cause any harm. Human error is inevitable and will never be eliminated. However we can only strive, through SQE approaches, to constantly improve systems and develop methods of reducing human error. Examples that may have reduced the risk of human error in this example are: prominently placed hand washing pumps at every patient bedside, empowering the patient to encourage handwashing of all staff, email alerts directly to all medical staff, weekly review of any updates and new protocols at all teaching sessions along with a signature register to verify if all staff have been informed and finally, encouraging all foundation doctors to not start a discharge letter until the most recent entry in patient notes is checked.

  91. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    The environment seems harsh, cold, and toxic. I would like to see a more friendly and open relationship between the individuals in the operating theatre. this will improve communication and overall success. Also, it will help avoid any more near misses.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Poor hygiene (forgetting to wash hands), this is something that should be remembered as there are usually signs everywhere reminding doctors to do so. this is not something that an F2 doctor should be forgetting to do. Forgetting to write a patient note is also a big issue. the way to prevent this is to have a doctor focus on one thing at a time to avoid forgetting something. or making sure to write it down herself. these mistakes and others where made due to lack of focus. The doctors should be more vigilant and take their time whenever possible.

  92. Anonymous says:

    1: The culture in the operating theatre appears toxic and unsupportive. Less senior staff are afraid of voicing their opinions or concerns for fear of being berated by the most senior surgeon, Mr Jones. Less senior staff could therefore be less likely to speak up about possible issues in future, which may ultimately have a negative impact on a patient’s safety. Although Mr Jones is likely stressed, especially after experiencing this near miss, he should instead be fostering a supportive environment in which staff can continually reflect on and improve their skills and how they treat patients, rather than being quick to place blame.

    2: Dr Patel’s previous interaction with Mr Jones after Jane’s operation had left her distracted, and she therefore forgotten to wash her hands after examining a patient with an infected surgical wound. After inadvertently passing the infection onto Jane, Dr Patel again forgot to report this in Jane’s medial notes, after being asked to examine another patient by a colleague. To avoid distractions getting in the way of a patient’s treatment, Dr Patel could have taken a moment to collect her thoughts and put the incident out of her mind – however, this is often difficult to do, especially when patients need to be seen. The F2 treating Jane after Dr Patel’s shift ended also discharged Jane without a quick examination – taking the time to ask Jane a few questions about how she was feeling after her surgery could possibly have brought the infection to the F2’s attention. There also seems to be a lack of communication between healthcare and administrative staff regarding new protocols. Dr Patel missed the meeting regarding the new wound infection protocol, and therefore Jane has not received the appropriate treatment for her infection. If an email summarising the key points of the meeting had been sent to staff, or if posters had been placed on wards or in staff breakrooms, this could have been avoided.

  93. Anonymous says:

    1. The experienced surgeon has created a culture where people do not generally feel comfortable in raising their concerns. The way he reacted to learning that a near miss almost occurred was not constructive because while his frustration was understandable, he made a nurse leave the room in tears rather than having a conversation with her about what went wrong and how it could have been prevented. The main change that needs to happen is that everyone involved in the surgery should have respect for each other and acts a more of a team rather than feeling intimidated by Mr Jones. If everyone feels comfortable enough to speak up, patient safety will be improved as it is less likely that mistakes will be made.
    2. The problems with Jane’s care following her surgery are mainly related to infection control. Dr Patel was distracted and forgot the normal protocol for handwashing between patients which has caused Jane extra and unnecessary complications and discomfort which could affect her recovery. She was also unaware of the new protocol for dealing with infections in the hospital and there was a lack of communication between different members of Jane’s team- Dr Patel did not leave enough information and Dr Lynch did not check the last entry in Jane’s file. This has led to her being discharged from hospital when she is not yet well enough to go home. As a results, her care will be compromised and her condition could deteriorate as she is less likely to receive the treatment she needed. As Dr Patel was unaware of the new protocol to treat infections within an hour of discovering them, Jane will have to wait for much longer to be treated which will impact on her recovery. By improving communication between team members, ensuring that hygiene rules are always followed and examining patient notes more carefully, these mistakes could have been avoided.

  94. Anonymous says:

    Please comment on the apparent culture in the operating theatre. What would you like to see change?
    There is a clear chain of command which is necessary. However, a fear of communicating any suspicions of errors is also present with this chain of command. An environment in which open communication occurs naturally without fear must be adopted
    What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Dr. Patel has forgotten to wash her hands, clear signposting reminding proper handwashing posted beside the door when leaving could ensure that proper handwashing procedure is always adhered too. Jane has also left with an infection, Dr. Patel may have been better ensuring antibiotics have been given personally or asking another member of staff to ensure a

  95. Anonymous says:

    1. The culture in the operating theatre is that of fear and humiliation where the senior surgeon, Mr Jones is in charge and everyone else is below him. Mr Jones’s colleagues are terrified of him and anticipate humiliation to the point where someone is scared to speak up about a potential mistake in the surgery for fear of being berated by Mr Jones. The fact that a junior nurse ran out of theatre crying is a disgrace and no one should be made to feel like that by a colleague, regardless of how senior or experienced they are. Mr Jones needs to change his attitude and become more of a team player rather than a bully. He should take more time to listen to his colleagues, work with the whole surgical team and support everyone, instead of shouting and humiliating them. People should not be scared to speak concerns about patient safety, Mr Jones is the cause of this fear and it needs to change.
    2. The problems in Jane’s aftercare include Dr Patel forgetting to wash her hands after examining a patient and reviewing Jane, causing spread of infection to Jane. Subsequently she was unaware of the protocol in place for infection of surgical wounds, meaning that Jane did not receive antibiotics straight away to battle the infection. Additionally when Dr Paten finished her shift she forgot to communicate to the F2 doctor taking over from her about Jane’s infection and Jane was subsequently prematurely discharged and her safety is put at risk because of these actions. These mistakes could have been avoided by remembering simple hygiene, Dr Patel ensuring herself that Jane received the necessary antibiotics or delivered the information to Dr Lynch herself about Jane’s current condition.

  96. Anonymous says:

    1. There seems to be a culture of hierarchy, authority, and blame in this operating theatre. The senior surgeon seems to be the one in charge, taking it upon himself to reprimand other members of the team, and creating an atmosphere where he must always be right, and that no one should dare to challenge him or believe themselves to be as smart or as skilled as him. The nurses and doctors seem scared and sheepish around him, anticipating that they will be humiliated or upset, and the fact that a junior nurse had to run out crying is ridiculous. One bad experience during your day can cause a ripple effect, ruining your concentration and attitude for the rest of the day, something that is very dangerous as a healthcare provider. Therefore, not only is Mr Jones’ behaviour affecting his team members in the operating theatre, but it also goes onto affect their patients as well. This affects the quality of patient care and the mental health of hospital workers, highlighting that it is of utmost importance that this situation and environment should be changed. There should be more evidence of a relaxed environment, where all team members are valued equally. Every single person present in the operating theatre with the surgeon is equally as important as if one member isn’t present or isn’t able to do their part, the whole procedure would be affected adversely. The importance of patient safety is paramount and members of the MDT should always feel comfortable voicing concerns.
    2. Dr. Patel should have remembered to catch up on what was involved in the meeting that she was unable to attend. Jane’s notes should have been updated clearly about the infection, and Dr Patel should have not got distracted so immediately by the other patient, and she should have remembered her hygiene and prevention of infection. These mistakes are all arguably due to her bad experience earlier in the day. This is an example of how doctors should always remember to be resilient and thick-skinned, and try their best to not let any personal or emotional issues affect their standard of patient care. However, I appreciate that this can be a very difficult thing to do.

  97. Anonymous says:

    The operating theatre does not seem like an atmosphere that is welcoming . The hierarchy of positions plays a big role here and even though sometimes this can be good in terms of task allocation and leadership , in situations like this where people at be top positions seem to look arrogant and unwilling to accept mistakes , could lead to other doctors and nurses being scared to raise a problem openly with their seniors . This can be detrimental to patient safety and also is quite demeaning because staff won’t feel satisfied working in an environment where they aren’t listened to or respected .

    One of the main problems with Jane’s care was the failure for Dr Patel to release that she is contaminating the patient with an infection because she missed to follow a serious protocol of washing hands before patient contact . Even though this looks like a trivial task, the consequences of not following this could lead to an unfortunate incident like Jane’s incident . Also the fact that Dr Patel missed the talk on antibiotic administration is again putting patient safety at risk . Therefore the hospital should make it compulsory for all staff to attend relevant talks

  98. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    The culture in the operating theatre appears to neglect the value of the multidisciplinary team and instead focuses on the importance of the surgeon’s opinion whilst minimising the input of the other team members. This creates an environment where staff are afraid to suggest ideas and raise concerns. This negatively impacts the wellbeing of staff and affects the safety of patient care.

    The culture needs to be changed from the beginning of medical training. The importance of every member in the healthcare team should be taught from the first year of medical school. Inter professional learning should be integrated throughout the course ensuring that medical students and ultimately doctors do not isolate themselves from working with other professions. Furthermore, the attitude of the surgeon needs to be addressed to ensure that staff are not afraid to raise concerns and work in an environment that prioritises respect and honesty.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?

    A major problem is the cross-contamination due to the fact that Jane failed to wash her hands after inspecting the other patients post-op wound infection. Jane may need a few moments for reflection to compose herself after the upsetting incident with the surgeon which would allow her to regain perspective and ensure that she is fit to practice.

    Consequently, Jane does not receive antibiotics within one hour of infection. Although Dr Patel was unable to attend the briefing regarding post-op wound infection she should have been briefed so that she is up to date with current regulations. Protocols should be in place whereby all staff must undergo mandatory training to ensure all staff are au fait with current guidelines.

    Rather than relying on written notes to transmit information, a briefing at handover between Dr Patel and Dr Lynch should take place, reinforcing written records. This would enable a greater continuity in care.

    As the last entry in clinical notes is not noticed two members of staff could check the records ensuring that all grounds are met prior to the patient being discharged.

  99. Anonymous says:

    1)In the operating theatre, the environment is very tense and hostile. Mr Jones has been very rude towards the junior doctor and nursing staff which resulted in one of the junior nurses in tears. Not only is this a poor example of a good working relationship between team members but also communication skills are being inhibited as people will be scared to speak up about future problems in surgery, putting the patient’s safety at risk. Furthermore, Mr Jones did not take responsibility for forgetting to check the patient notes for the correct ankle and instead he blamed other colleagues. This negative reaction could be handled better next time by showing more respect for his team members and allowing opinions to be expressed without the air of judgement that is currently present.

    2)There are numerous subsequent problems in Jane’s care. Firstly, after being shouted at Dr Patel loses focus and concentration regarding other patients, putting their safety at risk. Dr Patel should have taken a few minutes to compose herself and evaluate whether her mental state would affect her work. Secondly, Dr Patel forgot to wash her hands after touching an infected wound. This is a very basic skill that is vital for patient health and safety. Also, Dr Patel did not attend the new post-op wound infection protocol meeting and therefore did not abide by the new protocol, resulting in Jane not receiving antibiotic administration. In the future, all doctors should be up to date with changes in protocol or rules before seeing any more patients as this could affect the way in which treatment is administered. Furthermore, due to time constraints, Dr Patel is rushed away from Jane before she can make a note about the infection for the next F2 doctor on duty. Finally, Dr Lynch does not look at the last entry of Jane’s clinical notes and discharges her even though she has an infection. To avoid this, a final examination of the patient should be done on the day of the discharge with things such as temperature and the healing of the wound taken into consideration.

  100. Anonymous says:

    1. Within the theatre the atmosphere is very tense and hostile amongst the staff. From this episode we can see that many of the staff are afraid to raise concerns within the theatre in fear of being humiliated or criticised by Dr Jones. This is not an environment that breeds good teamwork or effective communication between staff which could lead to serious issues like the one discussed regarding Jane’s leg. Although within the team Dr Jones needs to take a leadership role managing the others within the team a change needs to be made regarding the way in which Mr Jones acts towards his colleagues to ensure that everyone feels respected. This will help to promote patient safety and good practice in the theatre.

    2. There are multiple problems that I can identify that have happened sin this episode. Firstly, Dr Patel has been annoyed from her earlier experience with Dr Jones in theatre and has not been able to move on from these feelings and so is not fully concentrated on the ward. A doctor needs to always be fully concentrated to minimise the risk of mistakes. Dr Patel should have given herself a break and tried to clear her mind and re focus before starting on the ward to maintain patient safety. The next problem relates to infection control Infection, despite Dr Patel using gloves with the first patient she needs to remember to wash he hands before she leaves that patient and before she examines Jane’s leg. Hand washing is a very basic skill but vitally important to prevent infection which could be critical for some patients. Dr Patel was also not up to date on the hospital protocol and although she could not attend the training, she should have taken time to read through the changes and update her knowledge. Lack of time has also led to several problems within this episode starting with Dr Patel trying to manage too many tasks at once. She failed to fully document Jane’s required treatment for the incoming F2 doctor and so led to the infection being missed by the F2 doctor. However, Dr Patel did include the infection in Jane’s notes and so one of the other members of the team should have picked up on it. The next issue was regarding the discharge Dr Patel rushed the discharge and did not read her own notes clearly and again missed the infection written down. Before the patient was discharged if her temperature was checked again the infection could have been discovered allowing treatment to start. Despite many problems arising with patient care within this episode many of the issues can easily be resolved with more attention and time given to each task and better communication between staff members.

  101. Anonymous says:

    1. A culture of hostility is apparent within the operating theatre. This is due to Mr. Jones’ outburst at the team, which creates an environment where fear and anxiety is prevalent. A hierarchy is established within the team as Mr. Jones seems to believe he is the most important person in the room. This is seen as rather than acknowledging his own fault in not checking the notes beforehand, Mr. Jones immediately blames the junior doctor and nursing staff. In addition, his outburst brought a member of staff to tears, thus, revealing how his actions impact the mental health of the people around him and somewhat justify their fears and anxiety in speaking up. I understand that the time pressure and potential consequences impacted Mr. Jones’ behaviour but it does not justify his attack on the staff. Mr. Jones’ actions in humiliating individuals in his team creates an environment in which speaking up is not encouraged and this will have a significant impact on patient safety in the future.
    In relation to improvements, Mr. Jones should’ve taken some responsibility for the near miss and properly addressed the team in order to ensure a lesson had been learned and the situation would be avoided in the future. The near miss should be documented and appropriate measures should be put in place to avoid future errors. I think that Mr. Jones should’ve spoken respectively and openly to his team in order to reach the cause of the near miss rather than his approach of humiliation and shaming of the individual raising the concern. This would create an environment that encourages speaking up and would improve patient safety in the future.

    2. The subsequent problems in Jane’s care arise from poor communication and a breach of hand-washing protocol. The first issue is that Dr. Patel shouldn’t have made assumptions about Jane’s complaints of pain and provided a more thorough examination. In addition, Dr. Patel did not wash her hands after seeing an infected patient, thus, leading to Jane becoming infected. Although Dr. Patel didn’t attend the course relating to this issue, the situation had the potential to be rectified by Dr. Patel informing the appropriate person of the infection. As Dr. Patel failed to make a note of the issue, the infection was left untreated as antibiotics were not administered. Dr. Patel’s actions and errors have negatively impacted Jane’s safety. Dr. Patel should’ve composed herself and moved on from the altercation in the operating theatre to allow her to focus on her next patients. These errors could’ve been avoided if Dr. Patel had followed the appropriate hand-washing policies, investigated Jane’s pain complaints more thoroughly, had made a note of Jane’s infection immediately after discovery and had kept up to date with hospital protocols in relation to treating this problem. Overall, more time and thought would have prevented this situation from arising.

  102. Anonymous says:

    In the operating theatre it is seen that there is a sense of hierarchy within the MDT, firstly with Dr Patel not feeling like he can bring up the doubt she has over whether it is the correct leg to her senior colleague Mr Jones. Something such as this should be easy when working in a team as you should feel comfortable raising any concerns you may have without any thought of backlash from it. Further more The reaction from Mr Jones highlights that he believes it isn’t his duty to double check the correct sight for the operation when really he is also responsible for this as it is as much his patent as anyone else’s in the room, and therefore just because he is the surgeon doesn’t mean that he doesn’t have the duty to ensure patient safety by simply re-checking that he is about to operate on the correct leg. It can also be seen that the sister Higgins response to Mr Jones after being told of the problem is quite a tell tail like retort as she explains that she was only just told by Dr Patel of the situation however he is not the only one responsible for the patient. Mr Jones’s harsh outburst at Dr Patel and Sister Higgins creates a sense of embarrassment and have created a slight fear, and so may affect situations in the future where an aspect f concern should be raised but isn’t as a result of them being uncomfortable around Mr Jones to be able to raise it.
    Jane’s care after surgery seems rushed and not high on the agenda, when Dr Patel indicates that the pain Jane has started to feel must be as a result of her bandages being too tight it seems that other factors could have been overlooked, which could be contributing to the pain, and without a more thorough examination they may be missed. Furthermore despite Dr Patel feeling overwhelmed after the near miss and quite public humiliation by Mr Jones there is no excuse to then go on to create a concern for patient safety through forgetting to wash her hands between patient. Dr Patel maybe should have taken a few minutes to bring her thoughts together after the situation and ensure that she goes on with the rest of her day with a clear mind so that she can process the tasks at hand better, and therefore would maybe not have forgotten to wash her hands before seeing Jane. There is also the problem that Dr Patel is not up-to-date with the new guidelines expressed when finding a site of infection after surgery, which in this case could cause detrimental impact on the patient, as she is unaware of the urgency to prescribe antibiotics. Which if she had know of the updated wound infection control plans may have been done before she left the hospital so the hand over would have been smoother. Despite this, Dr Lynch also appeared to overlook the last entry in Jane’s notes regarding the presence of an infection, which can suggest she was rushed and didn’t carefully read them before going ahead to write a discharge letter. It is also surprising that Dr Lynch doesn’t examine Jane herself to check that she is fit to go home; by not doing so it results in Jane leaving with an infected wound that could cause a multitude of other risks. These problems could be rectified by the doctors by ensuring that they are being thorough when carrying out examinations on patients or when reading their notes, whilst also putting a priority on maintaining knowledge of any new protocols that are being implemented in the hospital ensuring they are up-to-date. As for Dr Patel forgetting to wash her hands, i think it is important that after an intense situation she have a few minutes to reflect on what happens and put into prospect how she could have done it differently but then it is essential that she is able to move on from it and carry on her day as she would have done before, this mechanism would also ensure that she protects her mental health ensuring she remains fit to practice.

  103. Anonymous says:

    1. In the operating theater there is a culture of fear exerted by the surgeon and as a result his colleagues are afraid to speak up if they notice that a mistake was made and this can lead to catastrophic results. Also, the nurse is being shouted at, meaning that she might not speak up in the future or she might be reluctant to speaking, which means wasted precious time. In addition, the nurse that made the mistake will probably present confidence issues in the future, which could affect her work and progress. I appreciate that in cases of stress and especially when such major mistakes are almost made the pressure is very big, especially on the doctor, but making the persons responsible for the mistake aware of their mistake can be done in a different manner. There is no need and no help in shouting at them, especially if this is a first-time mistake. A civilized talk carried with the person at fault could be of much more help in the future than scolding them publicly and humiliating them.
    2. Subsequent problems that occurred in Jane’s case were:
    • Dr Patel being too distracted about the previous incident to realize she did not wash her hands between patient and therefore contaminating Jane’s incision. This could be solved by changing the culture of the hospital in which junior doctors are afraid to bring up an issue with a senior colleague due to a possible future scolding or upsetting the senior doctor.
    • Dr Patel being called to examine another patient before completing Jane’s notes and forgetting to mention the infection. This could be solved by Dr Patel making a small note in the notes of the patient simply stating “infection” so that even in case she forgets to come back to them the next doctor can see there might be an issue with the patient and check what exactly is happening. In addition, Dr Patel could make a small note for herself to see to remember to go back and finish completing the chart.
    • Dr Patel not attending the meeting about the change in protocol regarding infections in patients, which could be solved by the hospital sending an email to all staff members, following the meeting, in which to briefly state the meeting points. This would make all doctors aware of the change in protocol, even if they missed the meeting. In addition, announcements could be put around the hospital, saying that there was a change in protocol.
    • The second F2 doctor discharging Jane based in the nurse telling him that the husband came to take Jane home and that he only needs to sign the discharging papers without re-checking the patient. This could be avoided by having the doctor perform a quick examination before signing the discharge papers on a patient.

  104. Anonymous says:

    1. It is apparent that there is a blame culture present in the operating theatre, particularly with regards to Mr Jones, who seems to be very quick to place the blame on the junior doctors and nursing staff. Mr Jones appears to be quite hostile towards his colleagues and is publicly humiliating them, rather than communicating with them calmly and effectively. As a result, his colleagues are reluctant to speak up if they have concerns, which is actually putting patient safety more a risk. Therefore, I would like to see the theatre become a more respectful environment whereby colleagues can openly express their concerns without the fear of being dismissed or humiliated. This would help make the working environment a more relaxing environment for all staff and could lead to better care of the patient.

    2. Jane has suffered a healthcare associated infection due to Dr Patel’s clinical negligence in failing to wash her hands in between seeing patients. However, it must be noted that this was a result of the ongoing psychological effect of how she was treated in theatre earlier that day. This could have been rectified if Dr Patel had been more focused after the difficult morning in theatre and remembered to wash her hands. Perhaps she could’ve spoken to a colleague to help get the issues off her chest. There was also a breakdown in care regarding Dr Patel’s failure to communicate with the oncoming Dr Lynch regarding Jane’s infection, which subsequently led her to being discharged when she is not in a good condition, which may worsen without the treatment of antibiotics. These problems could be resolved by better communication skills being used by the team in the ward so that knowledge of Jane’s situation was passed on to the next shift. Moreover, Dr Patel should have made sure to catch up on the new briefing she missed, for example, by asking a colleague to fill her in. Also, Dr Lynch should have done a final check of Janes leg and her notes, before discharging her to ensure that she was well enough to be discharged.

  105. Anonymous says:

    1. The operating theatre seems to have a hostile environment in which people feel very afraid to speak up. There appears to be a blame culture. Instead of blaming and shouting I would like to see the whole team involved in focusing on the root of the problem and being logical in how to prevent this happening in the future. The culture in the operating theatre shouldn’t be upsetting as it was in this situation when one of the junior nurses left the crying. There should be an improvement with regards to communication in the operating theatre. Dr Patel tries to explain the situation but Mr Jones refuses to listen. Mr Jones shouldn’t have lead as a dictator by not listening to Dr Patel but instead let her explain. Better communication and a culture where everyone feels confident and able to speak would be better for the patient and the multidisciplinary team.

    2. Firstly Dr Patel forgets to wash her hands before she examines Janes leg. This leads to the leg infection and a mild temperature. Dr Patel prescribed antibiotics in order to treat the infection, however this situation could’ve been avoided by Dr Patel being more conscientious about washing her hands. The next problem in Janes story was that Dr Patel didn’t know about the new antibiotic administration programme. This ultimately lead to Jane being discharged from hospital with a leg infection without antibiotics. This situation could’ve been rectified if Jane had made sure to catch up on the briefing she missed. Also Dr Lynch should have done a final check of Janes leg and her notes, before discharging her.

  106. Anonymous says:

    1. It appears that Mr Jones is running a “dictatorship” in the operating theatre. There is a sense of hostility, with staff reluctant to raise any concerns out of fear of humiliation or being publicly reprimanded. This, in turn, can have negative consequences on patient treatment and safety. Not only does it mean that staff are hesitant when it comes to querying potential errors, but creates an extremely pressurised working environment which may increase the likelihood of mistakes being made, compromising patient care. The ideal environment in an operating theatre is one of shared responsibility, where staff, including juniors, feel confident enough to raise concerns, knowing that they will be listened to and not instantly dismissed. I believe that this change can be brought about by having more multidisciplinary team meetings where there is a sense of openness between staff members – for example, in relation to a mistake being made, joint discussions should be had to allow policies to be put in place to try to prevent similar errors happening in the future.
    2. By failing to wash her hands after seeing a patient, Dr Patel has caused Jane to develop an infection. It appears as though Mr Jones’ earlier criticism has resounded with Dr Patel and this has led her to become distracted. Whilst this is a natural reaction, it is important that Dr Patel has some coping mechanisms (for example, mindfulness techniques such as taking a few deep breaths) in order to gather her thoughts and focus before moving on to deal with the next patient. This will help to ensure that patient safety is not compromised. Due to missing the briefing on new hospital protocol regarding post-op wound infections, Dr Patel is unaware that she should begin administrating antibiotics within one hour of the discovery of an infected surgical site, instead making a note in Jane’s patient record for the next F2 doctor. The hospital should have a system in place for healthcare workers who missed briefings to be informed and explained details regarding any new policies. Staff should also take the initiative and enquire about any information surrounding policies which they may have missed. Furthermore, Dr Lynch should also have checked Jane’s patient notes before writing a discharge letter as the patient was not in a fit state to be allowed home. Jane’s infection will most likely worsen due to a lack of treatment, and she may have to come back into hospital to be administered the correct antibiotics. Not only does that have a negative impact on Jane’s health, but may also cause her to lose trust in the healthcare profession.

  107. Anonymous says:

    My Views on Jane’s Story Episode 4
    As was shown in Episode 3 Mr Jones creates an environment of fear in the hospital. Dr Patel was worried she would be publicly humiliated, and her fears were confirmed even though she was correct in what she did. She now feels guilty for not stepping forward earlier, but this incident may make her even more hesitant to come forward in the future.
    Dr Patel is distracted, and this can and does go on to affect her work. Before doing anything in the hospital you should use the IM SAFE (Illness, Medication, Stress, Alcohol, Fatigue and Eating/ Emotion) checklist to ensure you don’t make silly but serious mistakes such as this. Dr Patel should have removed herself for a few minutes to calm down before seeing further patients. Usually a good rule of thumb in any situation is to limit the time and number of people that are involved – so instead of passing something on to a nurse then a doctor the following day its best to just get it done then and there yourself. This isn’t always possible but would have avoided yet another error in this situation.
    It is important to attend any courses or meetings and keep up-to-date when working, if you can’t make it you should make a point to catch up on what was said or rearrange another day to attend if possible.
    Dr Lynch should have read Jane’s notes before doing anything. As this situation shows you never know what has happened when you are not there and what staff know what, patients notes allow all doctors to be on the same page and should always be utilised. Failing that even speaking to jane or giving her a quick examination before discharging her she should have been able to tell there was a slight infection.

    Please comment on the apparent culture in the operating theatre. What would you like to see change?
    There is most certainly in this situation an environment of fear and a clear hierarchy. While there is a need for a certain amount of hierarchy – Mr Jones is the surgeon and is the most knowledgeable about his area of expertise – there should also be a feeling of being in a team. If you work an environment of fear mistakes will be made and in an environment such a s an operating room these are more than likely serious mistakes. Everyone within the ‘team’ should be able to voice their opinions and concerns and they should be listened to not reprimanded. As I said in Episode 3 even the most skilled doctors can make mistakes and they rely on this ‘team’ system to ensure that this doesn’t lead to harming the patient in any way. Being in an operating room is already a high stress environment and having people around you are comfortable working with and can trust (to listen to you and to speak up) things become a lot smoother. As a doctor it is important to reflect on and learn from your mistakes and Mr Jones is not allowing this to happen just passing the blame to his ‘inferiors’ so he will never learn and while the mistake was saved this time it might not be next time.
    There are many things I would like to see changed about this environment. There should be a sense of being one team rather than a surgeon and his helpers. Doctors and other healthcare workers need to be more comfortable and confident in speaking up but also be able to listen to others when they do speak up. No one should have to work in fear it adds more stress to an already stressful situation.

    What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Jane is now being discharged with an infection which has been missed by Dr Lynch. Dr Patel was under stress and distracted and this caused her to infect a patient – a silly but potentially life-threatening mistake.
    Dr Patel should have removed herself for a few minutes to calm down before seeing further patients. Dr Patel could have made a point to get the antibiotics there and then rather than passing on the information to two separate people. She also should have caught up with a colleague to fill her in on what she missed at the protocol meeting before starting work.
    Dr Lynch should have read Jane’s notes before doing anything. She also should have given her an examination or at least spoken to her before discharging her.

  108. Anonymous says:

    1. There is very much a hierarchical system and blame culture present in the operating theatre. Everyone seems to be have put into a place and feel unable to speak out against superiors, which is very inappropriate. Healthcare is a system that requires teamwork and deconstruction of a hierarchical system. Professionals should feel able to speak out when they are unsure or have recognized that a mistake has been made without feeling negative repercussions. Teamwork should be encouraged and different healthcare professionals should feel comfortable discussing cases. The lead surgeon cannot admit fault and blames his ‘inferiors’. This is incredibly inappropriate. In healthcare, you should be able to recognize and admit your mistakes as this enables you to reflect and learn to ensure that the same mistakes do not occur again. The operating theatre is an intense, stressful environment, and there should be a less cold, more supportive and communicative culture in place.
    2. Dr. Patel failed to follow correct hygiene protocol by forgetting to wash her hands, and as a consequence, an infection has been passed onto Jane. Alongside this, Dr. Patel has not effectively passed on information to the F2 doctor on post-operative care. Dr. Lynch, the on-call F2, has not correctly read Jane’s patient notes. These issues could be rectified by Dr. Patel taking more due care and attention to proper hygiene protocol to prevent the spread of infection, which could easily be done by taking note of the hygiene posters likely displayed across the hospital. If Dr. Patel was at least aware that there was a change in protocol for the administration of antibiotics, she could have asked a doctor or other staff member who did attend the briefing to catch her up with the new protocol to tide her over until she can get a formal briefing on the procedure. To ensure the next F2 was aware of the infection, Dr. Patel could have asked another member of staff on Jane’s case, such as a nurse, to remind her to put a note in Jane’s notes or at least inform multiple members of staff. Alongside this, before discharging Jane, Dr. Lynch or nurse could have performed a final check on Jane’s surgical site to determine whether she was still okay to be discharged.

  109. Anonymous says:

    1. The operating theatre has a blame culture embedded within it. The senior surgeon was quick to blame the nursing staff and junior doctors for the mistake. The surgeon was quick to anger and reprimand his team publicly. I would like to see a change in these principles, where the entire surgical team feels comfortable to raise issues or concerns about the imminent operation without fear of being punished or publicly reprimanded. This comes with good leadership from the surgeon in charge as he is able to culture an atmosphere of calm and trust between his team.
    2. The problems with Jane’s care started with Dr Patel’s poor personal hygiene as she forgot to wash her hands which subsequently lead to the wound becoming infected. Dr Patel then forgot to write a note for the F2 doctor explaining that the Jane’s wound had become infected and that she would not be allowed to be discharged today. These problems could have been resolved if Dr Patel had taken greater care and followed procedure more strictly. Further failings in Jane’s care was allowed to happen as the F2 doctor discharged Jane without checking her notes which stated she had an infection in the wound preventing her from being discharged. These problems could be resolved by better communication skills being used by the whole team in the ward.

  110. Anonymous says:

    1. There is a culture of blame in the operating theatre which is evident when Mr Jones berates his colleagues, humiliating them, which makes the other members of the team less likely to speak up if another error occurs. The evident hierarchy in the surgical team is becoming detrimental to patient safety. There is a breakdown of communication and Mr Jones shows vey little empathy or respect to other members of the team. I think the atmosphere of the theatre should become more learning focussed, instead of focussing on blame. Allowing all members of the team to feel comfortable enough to speak up when there is an issue may reduce the incidence of errors and increase patient safety. A thorough pre-operative assessment should be made routine for all procedures to minimise the risk of this potential error occurring again.
    2. Dr Patel was distracted after the stressful operation and so used improper hand hygiene techniques which led to Jane’s post-operative wound becoming infected. Dr Patel’s distracted behaviour became a patient safety risk and could have been avoided if Dr Patel had been allowed to take a break after the stressful procedure. Dr Patel didn’t effectively communicate to Dr Lynch or a nurse that Jane had a suspected post-operative wound infection, meaning Jane is discharged and her condition will worsen. This could have been rectified by Dr Patel speaking to Dr Lynch or a nurse to communicate the issue or she could have finished making the note in the patient record before she went on to complete her next task. Dr Patel also should have taken the time to get caught up on the new protocols, so Jane could have received the antibiotics at the correct time. Dr Lynch should have checked for signs of infection and read Jane’s notes before discharging her.

  111. Anonymous says:

    1. The culture in the operating theatre appears to be hostile and very tense. It feels as though Mr Jones is viewed as a dictator in theatre by his colleagues rather than a leader. Consequently, Dr Patel and the other nurses do not want to go against anything Mr Jones says, even if it puts patient safety at risk, due to the hierarchy established. Mr Jones does not communicate well with his colleagues, is abrupt and although he may have empathy for his patient, he does not display this quality to his colleagues. What I would like to see change is Mr Jones’ leadership style whereby he listens to his colleagues and promotes a well-functioning multidisciplinary team. As a result, Dr Patel and the nurses would feel their concerns were respected and taken on board, benefitting both them as well as the patient.

    2. The lack of attention Jane has received since her operation will most likely compromise her safety. Dr Patel was clearly still dwelling on the incident that occurred in theatre and was distracted. By not following the correct hand hygiene procedures, she has unwittingly infected Jane. Although Dr Patel did notice the infection the following day, she hadn’t attended the meeting regarding a change of protocol for post-op wound infection. Therefore, antibiotics were not prescribed to Jane at the correct time and Dr Patel also forgot to leave a note for the next F2 meaning Jane was discharged when she shouldn’t have been. These mistakes could have been easily rectified. Had there been a well-functioning team in theatre, Dr Patel wouldn’t have felt distracted initially and the infection to Jane’s wound may not have occurred. Dr Patel should have made an effort to find out what the new protocol was after missing the meeting so antibiotics could have been given to Jane at the appropriate time. The F2 doctor also should have checked Jane’s leg and reviewed the notes before writing a discharge letter to send her home.

  112. Anonymous says:

    I would say there is a patriarchal culture in the operating theatre, the surgeon acts incredibly authoritarian, he has an inflated ego and its effects on the rest of the team are profound. An environment of fear and stress is created, in which questions cannot be raised and learning opportunities are not had. It is detrimental not only to the patients but also to the staff, in their working environment, as instead of an opportunity for progression and improvement, Dr.Patel feels cowed and embarrassed, one of the nurses is in tears. It is clear that this is not an environment for learning. I would prefer to see an environment where Dr.Patel or any of the rest of the surgery team felt they could freely question and challenge decisions which they felt were wrong, in a productive and conducive way, and in which mistakes were discussed in a team- with the focus not the blame placed on an individual but instead on root causes and future improvements. Dr.Jones should take the time to listen to any concerns of his team. This culture of blame and belittlement should never have a place in a hospital where patient safety should always be at the forefront of decisions.

    Dr.Patel should have washed her hands both after examining the other patient and before examining Jane, the subsequent spread of infection would have likely not happened. Also, due to her inability to attend the briefing on the new hospital policy, she doesn’t know about the new procedure, she should have been informed of the contents of the briefing by another staff member or by informative posters/ other methods to remind staff. Additionally, there was a breakdown in communication between shifts; Dr.Patel forgot to place her note to the F2 in her file (though I believe this could be avoided by communicating directly at handover), and the patient should still have been reviewed by the doctor who released her. Jane will be sent home with an infection which she does not know about, and without antibiotics it could become much worse and spread. Her care has been compromised by the repeated failures.

  113. Anonymous says:

    There appears to be, in some situations, an uncomfortable and tense atmosphere within the operating theatre. This is due to ineffective leadership from the lead surgeon, whereby others in the team feel unable to confront them over potential issues. It seems that there isn’t a good flow of communication due to fear of being reprimanded. I feel the operating theatre would benefit from having a more structured procedure to raise concerns whereby meaning everyone’s thoughts can be respected.
    Due to not washing her hands, Dr Patel has unknowingly contaminated Jane’s wound by not correctly following hygiene protocol. Dr Patel has also failed to effectively pass on essential information to the next doctor on duty. In order to solve these problems, Dr Patel should more closely follow correct hand washing procedure as well also making informing the next doctor a priority.

  114. Anonymous says:

    1. The culture in the operating theatre is quite hostile and tense. Mr Jones seems to be the head of the theatre and rather than being a leader, he acts as a dictator. This creates an unstable hierarchy, where the other members of staff do not feel like they have the right to speak or correct him, even if they know that it could save the patient. Lack of communication is present as there is fear attached with speaking to Mr Jones, as staff do not know how he may react. Teamwork is not present as Mr Jones tends to try and work as an individual, using the other members as prawns rather than valid players in the operating theatre. What I would like to see change is the way that Mr Jones interacts with the other staff members, as he is the lead surgeon, he should lead the staff in a better manner.

    2. Subsequent problems that I can identify in Jane’s care is the lack of attention given to Jane following her operations. Dr Patel became busy and was unable to give Jane the attention she requires and unknowingly infected her due to Dr Patel poorly following the correct hygiene protocol by not washing hand. Also since Dr Patel missed the meeting and failed to give Jane antibiotics within one hour as instructed by the new protocol. Jane, therefore, didn’t get the antibiotics because there was no transfer of information by Dr Patel to the new F2 doctor overseeing Janes case. Now Jane is at risk as the F2 doctor does not know about any possible infection and might discharge Jane. They can be rectified by Dr Patel ensuring that she follows the proper handwashing procedure to ensure that infection control occurs. Dr Patel can also show up to all meeting so new and vital information is not missed. Better communication between Dr Patel and the new F2 doctor need to occur as a note is not enough. Also, Dr Lynch needs to ensure that she looks at Janes note and check for any possible signs of infection before discharging her.

  115. Anonymous says:

    1.There needs to be a change between the operating staff in the theatre, mainly focusing on their communication skill. It needs to be clear that most are afraid to confront Dr.Jones as he come across snappy and aggressive. His attitude towards staff members is not acceptable and is putting patients at risk as they are then afraid to correct him. I believe the whole ward needs a communication skills workshop to help them progress as a team. Also that if a member of staff does something incorrectly that they should not be humiliated by their co-workers.

    2. The problems which have occurred in Janes arise from lack of communication. This being as she was unawarely near operated on, on the wrong leg. This was due to a breakdown in communication from the operating team. Another problem with Jane care is that in the beginning (story 1-3) he has been administered drugs which have a negative effect on her, and her trust was then effected in the health care teams as the doctor who administrated them did not apologise but ignored her in the hospital. Her trust was also tainted when the doctor did not trust her instinct that she had a more serious injury than they had indicated, which then appeared to be true in her following diagnosis (causing her unnecessary pain for 11 weeks) . Last she was given an infection before she left the hospital which could have been avoided if this doctor followed the guidelines on hand washing. Overall, most of these problems could have been avoided if adequate communication occurred among the health care team. Also if doctors listened to her concerns during her first diagnosis consultation, these problems could have been sorted sooner. Also the reading of notes effected Jane in 1 case but could have also effected her in the second (near operated on the wrong ankle) therefore they needed to insure that notes are read before administration of drugs occur or before operations occur (by the whole operating team). Lastly, ensuring doctors follow the necessary guideline such as hand washing to prevent infection would have also prevented janes current infection (perhaps a workshop on infectious control) and also to apologise to patient if you are in the wrong (giving drugs which effected her stomach) to restore the patients trust in the profession.

  116. Anonymous says:

    The culture in the operating theatre focusing on shouting and blaming other people for a mistake. There is no positive and open communication as a team. The surgeon focuses on trying to find someone to blame for the near miss and communication is aggressive and in a way to make the other doctors embarrassed. I would like to see more open honest and respectful communication to encourage people to speak up when they see a problem in order to prevent near misses such as Janes. There should be a more thorough pre operative procedure to ensure this doesn’t happen again. I would like to see less blaming and more communication in a positive way.

    Due to the near miss of operating on the wrong leg, the surgical staff rush to prepare janes left leg for surgery. In doing this the staff could have missed areas of her leg which needed disinfected and this may have led to the post operative wound becoming infected. Dr. Patel also failed to give Jane antibiotics as guided by the protocol within one hour of infection. This prolongs the time the bacteria are in the wound and may cause more damage to Jane. Because of the events at the surgery Dr. Patel is not concentrating on her patients and infects Jane due to not washing her hands in between patients. Jane doesn’t receive the antibiotics and the F2 also doesn’t get the note to give them. This results in Jane being discharged when she shouldn’t have been and leaves her wound infected.

  117. Anonymous says:

    1. It is evident that when Mr Jones is running the theatre, the atmosphere is uncomfortable and all those in the room fear that they may be reprimanded by the senior surgeon. Given that Mr Jones is infamous for his temperament, this seems to be a frequent occurrence. The theatre should be a more open environment where concerns like these can be raised without fear of being reprimanded and humiliated. This would result in the patients being safer and the work environment being less mentally taxing.

    2. Due to the public humiliation that Dr Patel underwent in the operating theatre, she is feeling defeated and upset, resulting in her being distracted. Additionally, since she did not attend the meeting so was unaware of the new protocol; this could be rectified by informing staff as soon as they get on their shift so that nobody is unsure or uninformed, as Dr Patel was. The cross contamination with the infection was due to a mistake made by Dr Patel that can be linked to her being distracted. This issue has led to multiple small lapses in memory that have caused the issue to escalate to a bigger problem than it initially was.

  118. Anonymous says:

    There appears to be a very tense atmosphere in the operating theatre because the nurses and junior doctors feel intimidated by Mr. Jones. His aggressive behaviour, coupled with the F2 doctors reluctancy to challenge him, suggests a very hierarchical culture in the room. I would like to see a more open environment adopted in the surgical theatre, one in which no one is afraid to raise issues regarding patient safety. If the staff felt their opinion was welcomed by the senior surgeons, then fewer incidents like this would occur and patients would benefit.

    The further issues regarding Jane’s care involve the F2 doctor and hospital policy. Firstly, Dr. Patel did not use appropriate hand hygiene techniques, posing and great danger to future patients. This should be mandatory and diligent hand washing could have prevented infection of Jane’s wound. Secondly, the F2 doctor did was not thorough in recording the infection of Jane’s wound, inevitably compromising her safety when she is discharged. Doctors should deal with one patient in great detail and then move onto the next patient, provided there are no other urgent cases. Finally, a complete examination of the patient and their notes should be carried out before discharge, possibly allowing missed item (e.g. infections) to be uncovered.

  119. Anonymous says:

    1. I think the current environment is not learner-friendly. Dr Patel nor the nurses felt comfortable raising a concern due to the fear of being berated by Mr Jones and feeling humiliated and incompetent. This kind of environment has the potential to be detrimental to patients as the teamwork is clearly ineffective and ceases to provide a good standard of care for Jane and any other patient that they treat. Furthermore, the team seems to be more concerned about completing their theatre list than providing the best care for the patients and these priorities should be adjusted to ensure patient safety.

    2. Subsequent problems in Jane’s care occur due to a few reasons. Firstly, Dr Patel’s poor hand hygiene causing Jane’s post operative wound to become infected. Secondly, the fact Dr Patel did not attend the new protocol meeting meaning that the antibiotics were not delivered efficiently. Also, Dr Lynch allowing Jane to be discharged with a post operative infection in which she had a temperature and needed antibiotics. These could have been rectified if Dr Patel administered good hand hygiene to help avoid Jane developing an infection. Also, Dr Patel could have caught up on what she missed at the new protocol meeting from a colleague and Dr Lynch could have checked Jane’s notes more thoroughly or at least examine Jane before she signed her discharge letter.

  120. Anonymous says:

    1. The operating theatre has a very hostile and negative environment that seems that have an impact on everyone. Mr Jones has made it so no one feels like they can raise any concerns or ask any questions about the procedure out of fear of being berated or yelled at in front of everyone else, which is the exact opposite of how a health care environment should be. Due to this almost dictatorship that Mr Jones has set up, the nurses and other doctors are afraid to do anything wrong or make any mistake, which in turn actually affects their performances and can have a negative impact on the patient. I would like to see the Theatre turn into a place where you are encouraged to raise any issues/concerns that you may have, and that you will be listened to and taken seriously instead of being dismissed. I feel like this would benefit all the healthcare workers in the theatre as they can all relax an work to the best of their abilities without being afraid to make a mistake, which overall will make the theatre a safer place for the patients where they can receive the best care possible.

    2. The verbal abuse that Dr Patel received from Mr Jones has quite clearly had a ripple effect for subsequent patients that she has seen. She has became very distracted and less focused on her work due to being upset from Mr Jones’s treatment of her and this has resulted in harm to Jane. Dr Patel has forgotten to wash her hands after dealing with an infected wound (failing to following standard protocol) which caused Jane to develop an infection. There has also been a lack of communication between the staff on this ward which has lead to this. Firstly, Jane has forgot to record the infection in the notes so that the F2 doctor on duty can prescribe her antibiotics to treat this within 24 hours. This lack of communication has allowed Jane to be discharged from the hospital by the current Doctor as he didn’t know about the infection, which will cause Jane to come to more harm as the infection is likely to get worse with out the recommended treatment. Secondly, Jane was also failed by a lack of communication between the hospital and Dr Patel as she should have been aware of the new protocol regarding infections which could have potentially changed the outcome of this scenario. This situation could be rectified by creating a more open and mindful working environment that respects every ones opinions. Dr Patel should have taken a few minutes to herself after the ordeal to calm herself and collect her thoughts before moving on to the next patients so that she is seeing them with with the best possible state of mind and attention that they require. The hospital should also have systems in place to inform doctors who have missed meetings of any new policies that have been brought in to avoid situations like this one.

  121. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    The attitudes of senior staff members being condescending to junior staff especially when challenged as it creates a bad working environment and makes junior staff less likely to speak up and raise any patient safety concerns. The way Dr Patel was treated also put her off her work for the rest of the day, compromising patient safety further. The environment should not be one of blame and rather be an open atmosphere where discussion is the standard and questions are answered respectfully, which would also make it a better teaching environment. If mistakes are made, procedures should be agreed upon and put in place to prevent similar mistakes being repeated.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    Dr Patel should have practiced effective hand washing to minimize the transmission of infections from patient to patient. The infection on the wound and Jane’s temperature should have been recorded in Jane’s notes so that Dr Lynch and other staff eg – nurses would see them upon examination of Jane and her notes so that the treatment could begin as soon as possible – as is recommended by the hospital’s policy. Dr Lynch should have checked Jane’s wound and her notes herself before writing the discharge letter as it is also her responsibility as being a fellow F2 doctor that only stable patients without complications be discharged. Dr Patel should make herself aware of the new hospital procedure on wound infections since she missed the information day previously, this should bring her in line with other doctors and ensure they are all giving the same standard of care to their patients.

  122. Anonymous says:

    1. Culture is the ideas, customs, and social behaviour of a particular people or society. The obvious culture in the operating theatre is hostile, aggressive and confrontational. The arrogant manner of Mr. Jones leads to the other staff feeling a lack of confidence in their skills and ability to speak up about issues which concern them. Ultimately this results in a lack of communication within the operating theatre and this ought to be changed in my opinion to avoid risks to patient safety. Therefore, I feel that the operating theatre should have a more positive atmosphere where staff can work together and express both skills and concerns for the good of patients and others.
    2. Jane suffered a healthcare associated infection caused by Dr Patel’s lapse of concentration when checking Jane’s wound in the afternoon due to the distractions as a result of the near miss in the theatre that morning and the psychological impact of this, and Jane’s lack of communication with Dr Lynch. This could be rectified by holding a staff meeting to discuss and analyze the root cause of the error, the best way to prevent this from reoccurring and to reassure staff members and discuss any of their concerns or issues. This way, I feel staff members would become more resilient and learn from each other’s mistakes to improve patient safety. Moreover, the 5 moments for hand hygiene, protocols of hospital and patient note taking could be revised in order to prevent problems in the future.

  123. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    The culture in the operating theatre is extremely tense, it is a place of fear and intimidation. The environment should be open and questions/queries should be welcomed instead of being rejected and dismissed. Humiliating the staff for speaking up could result in fear of questioning any of the surgeon’s decisions and ultimately damage patient safety. The surgeon’s treatment of Dr. Patel also distracted her from her work for the rest of the day, leading to more possibility of damaging patient safety. The environment should be changed to a more open environment where all staff is respected, ‘blame’ should not be placed on an individual and when mistakes are made, precautions should be put in place to never make the mistake again and to learn from it.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    There is a clear lack of a thorough examination by Dr. Patel on Jane and what is causing her pain. Dr. Patel should have personally told Dr. Lynch about the infection or a nurse and treated it in a more serious manner and should have washed her hands to prevent spreading infection as this is a fundamental role of a doctor. Dr. Patel is clearly still distracted and upset from the earlier encounter and should have taken a break or told a colleague as she was not in her right mindset. Dr. Lynch mistake of overlooking Janes’s clinical notes and this should have been avoided also.

  124. Anonymous says:

    1. Within the operating theatre, there is an apparent superior culture created by Mr. Jones, the surgeon. He communicates with his colleagues in a very poor, aggressive manner and makes his colleagues feel that they cannot approach him if they have a query or problem. This results in a very tense working environment which consequently creates poor communication within the theatre team. I would like to see Mr. Jones improve his communication skills and take responsibility for any error he makes and if his colleague makes a mistake, to approach the situation in private with his colleague, communicating in a more appropriate way. This will create better working relationships within the team, enabling the opportunity to learn from mistakes, which will allow for better patient surgical outcomes.

    2. There were numerous subsequent problems in Jane’s care. Firstly, Dr Patel did not follow infection control measures by forgetting to wash her hands after checking another patient’s infected wound, which resulted in Jane’s wound becoming infected. This could have been prevented if Dr Patel gave herself a few minutes to compose herself or talked to a colleague to what had happened in theatre to allow her to focus on the patients she would be examining next. Another problem that occurred is that Dr Patel forgot to record in Jane’s notes that her wound was starting to show signs of infection which required antibiotic treatment and delayed discharge. This resulted in the F2 doctor that was coming on duty to discharge Jane without any further concern. This could have been prevented by Dr Patel ensuring she recorded this important information. The staff should have ensured that the information regarding new protocol on wound care reached Dr Patel, so that she would have realised the urgency of the need for Jane receiving antibiotics and the importance of recording this. Dr Lynch, the F2 doctor, should have also examined Jane’s wound before discharging her.

  125. Anonymous says:

    1. The culture and atmosphere in the opening theatre appears to be very authoritarian and outdated. The surgeon seems to have an inflated ego that intimidates the rest of the staff, especially Dr Patel as she is too scared to speak up when she notices the error. Mr Jones doesn’t accept that the team as a whole has made an error and is quick to pass blame to the other staff members, humiliating them in the process. This is counter beneficial as it will not encourage staff members to speak up in the future if a similar situation arises and will only make them more scared of being reprimanded. I would like to see a change in this dynamic so that there is more functional multidisciplinary teamwork taking place. There should be more respect shown for other members of the team in the operating theatre and it should be made clear that there is no hierarchy present and everyone is working together for the same purpose; patient safety.
    2. Following the situation in the operating theatre, Dr Patel is so flustered that she makes further mistakes in her medical practice. Dr Patel forgets to wash her hands after examining a patient with a post op wound infection, posing a great risk to patient safety and her own safety. She then goes on to readjust Janes bandage, passing on the infection. This could have been avoided if Dr Patel had a system of washing her hands thoroughly before and after seeing every patient. Jane, who already had a pain in her leg post-op has now developed a post-op infection. Dr Patel missed the briefing of the new antibiotic protocol and so doesn’t know to administer an antibiotic to Jane straight away. This could have been avoided if Dr Patel had made an effort to catch up on everything she missed at the briefing and studied the new protocol or asked a colleague. Dr Patel then forgets to record the infection in the patients notes resulting in her being discharged without treatment. This could have been avoided if Dr Patel recorded the infection straight away before dealing with the other patient in order to ensure nothing had been overlooked in Janes treatment. Furthermore Dr Patel could’ve informed another member of the multidisciplinary team concerned with Janes treatment about the infection so that more people were aware and would know not to let her be discharged.

  126. Anonymous says:

    1.There is a blame culture in the operating room which is evident when Mr Jones publicly embarrasses and humiliates anyone who makes a mistake or even staff like Dr. Patel who raise concerns. This makes everyone in the operating room feel tense and worried to the point where they are scared to speak up and raise concerns and this endangers patient safety. There is also a clear hierarchy in the room in which Mr Jones is superior and everyone else is below him.
    I would like to see the environment become more open and to remove the blame culture so that people are not scared to raise concerns over patient safety. I would also like to see better communication between the team so that everyone is on the same page as to what is supposed to happen during the surgery.
    2. Dr, Patel forgets to wash her hands after touching the infected post-op wound, this caused infection to spread to Jane’s surgical wound. This could be prevented by having signs up to remind people to wash their hands.
    Secondly, Dr. Patel didn’t follow the new protocol of administering antibiotics within one hour of finding an infection in a surgical wound. To prevent this happening again Jane should find out about and learn the new protocol.
    Dr. Lynch then discharges Jane even though she has an infected wound and a raised temperature. To prevent this happening again the doctor should review the patient before sending them home.

  127. Anonymous says:

    1. There is a clear hierarchy in the operating theatre with the lead surgeon, Mr Jones, giving the impression that he does not want to be disturbed as he carries out the surgery. Therefore when Dr Patel notices that he is operating on the wrong leg, she finds it difficult to speak up with the fear that she might be wrong. When she finally does speak up Mr Jones shifts the blame of the ‘near-miss’ error and blames everyone else in the theatre for the mistake rather than himself, leaving everyone in a distraught state. In order to overcome this issue there should be an investigation into the fault in the system rather than the faults of individual people. If Mr Jones had come into theatre with a welcoming approach and showed signs of leadership as he created a calm and open environment in which everyone was involved, the mistake may not have happened as Dr Patel would not be afraid to speak up at the beginning. Overall, patient safety should be at the forefront of everything and the fear of being wrong or being shouted at should not overrule this.

    2. The subsequent problems caused by the initial situation in the operating theatre were that Dr Patel was in such a distraught state that she could not concentrate and she forgot to wash her hands between patients. This left Jane with an infected wound. In order to overcome this, multiple signs should be placed around the hospital to remind people to wash their hands. Also, someone could have noticed that Dr Patel was in a confused and distraught manner and may have suggested she took a few moments to gather her thoughts and get into the right head space to continue working to a high standard. Also, Dr Patel had missed the meeting about the new hygiene and antibiotic prescribing protocols which the hospital now use. By keeping all staff up to date with protocols either by sending an alert via email or signs in staff rooms Dr Patel would have known this information and prescribed the antibiotics appropriately. As well as this, Dr Patel forgot to inform the F2 doctor who was to take over about the infection Jane was developing which left Jane being discharged from hospital before she was ready. This could have been avoided by the F2 doctor carrying out an examination before discharging any patient or Dr Patel updating her patient notes before leaving the hospital despite being in a rush. This emphasises how patient safety must always come first.

  128. Anonymous says:

    1. Within in the operating theatre, its is apparent that there is a hierarchy within the medical team. The lead surgeon, Mr Jones appears to be the boss at the top, with the other members of staff well below him. Mr Jones is unwilling to take any responsibility for the ‘near-miss’ situation and quickly passes the blame onto Dr Patel and Sister Higgins. Also, he has shouted at the nursing team and left one of the junior nurses in so much distraught that she had to leave the room. He was unwilling to listen to what Dr Patel had to say to explain herself and lectured them on what could have went wrong. However, if Dr Patel and Sister Higgins had not have spoken up then the wrong leg would have probably been operated on.

    I would like to see a more relaxed environment within the operating room, with all members of staff feeling comfortable and valued that they can speak up about any issues or concerns they have at any time. Everyone, including the lead surgeon, should take the time to listen and communicate effectively with others and make everyone present feel equal and not looked down upon. In the case of a ‘near-miss’ situation arising again or if an actual mistake occurs, blame shouldn’t be pinned down on one person; all members of staff should try to resolve to problem and look at ways in which it can be prevented if it was to occur again in the future.

    2. Jane’s wound manages to get infected from the previous patient Dr Patel examined before her. This could have been prevented by Dr Patel washing her hands after viewing the patient with the post-op wound infection. Naturally, Dr Patel was in a distracted state after the incident which occurred in the operating room earlier in the day and she finds it hard to maintain her concentration and focus when seeing patients on the ward. She should have remembered her basic clinical hygiene procedures and if the case more signs such be placed around the ward to inform patient, staff and visitors of the importance of hand washing.
    Also, Dr Patel was not present at the briefing about a new post-op wound infection protocol which recently occurred in the hospital. Due to this, Dr Patel doesn’t follow the guidelines to start antibiotic administration within the hour of discovering the infection and doesn’t stick to the hospital’s protocol. This could have been rectified by the staff that did attend informing Dr Patel of what she missed and stressing the importance of the meeting to her; perhaps even giving her some resources that she could study to get her up to speed with the new procedure in place.
    Additionally, Dr Patel forgets to leave a note in Jane’s patient records for the next F2 doctor and leaves the hospital without any communication to other members of the team of Jane’s infection and therefore nobody else is aware of Jane’s condition. This could have been prevented by Dr Patel quickly writing a note in the records or a note to herself to notify the oncoming F2, Dr Lynch of the situation before she got distracted by attending to another patient.
    Finally, Jane is discharged from the hospital by Dr Lynch and she goes home with an infected wound. To prevent this from occurring, the doctor should have examined Jane and her wound before writing a letter and discharging her.

  129. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?

    Nobody should be reprimanded by being shouted at or pointing fingers at who made what mistake. The most important thing is the patients safety and how this situation can be prevented from happening again. I would see to it the surgeon also gets told off for the way he treated the sisters because it wasn’t considerate and it won’t help any similar situation in the future if people are to scared to say anything. Of course the sister shouldn’t be let off but that is not the correct way to deal with this near miss situation.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?

    The doctor that inspected her wound didn’t wash their hands and resulted in unnecessary infection this goes against the ethical pillar of non-maleficence and the patients safety is at high risk. Especially with the doctor not writing in the patients notes about the infection resulting in them being sent home with an infection and a temperature. As there was a shift change. The doctor should have taken the time to finish the task at hand before moving onto the next one as it resulted in them forgetting to write about the infection.

  130. Anonymous says:

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?
    There seems to be a culture of strict authority by Mr Jones, which creates fear among the other operating theatre staff. The other theatre staff seem intimidated by his authority, which makes them reluctant to confront him due to his harsh attitude towards them. I think that this attitude by Mr Jones towards the other staff needs to be immediately addressed so that the staff feel comfortable voicing their concerns to him. This improved communication and team work among theatre staff would create a more positive and safer patient environment, allowing the provision of a higher standard of care. I would also like the culture of blame to be addressed, allowing staff to focus on identifying how future errors can be avoided through implementing a better system, rather than focusing on someone to blame. In addition, there should be a better culture of speaking and listening to allow staff to express their feelings, rather than attempting to carry on working whilst being upset and unfocused, which could potentially put patients at risk.
    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?
    The failure to remember to wash hands between patients led to Jane catching an infection. To try to reduce the risk of this error occurring again, mandatory training could be provided to staff to remind them of the importance of hand washing. There could also be reminders put in place to reduce the risk of staff forgetting to wash their hands between patients, for example handwashing signs. By being discharged with an infection, Jane’s infection might progress and cause further complications to her recovery. To rectify this, an apology should be offered to Jane for this error and she should be started on a course of antibiotics immediately once the infection is recognised. To reduce the risk of this happening again, a note should be taken of what staff members were unable to attend the meeting to learn about the new protocols and they should be informed about these at the next available opportunity, ideally as soon as possible. In addition, where possible staff should attempt to finish making any required notes about the patient prior to moving on to the next patient to minimise the risk of information not being passed on appropriately.

  131. Anonymous says:

    1. The culture in the operating theatre seems to be intensely hierarchical, where Mr. Jones accepts no responsibility for the near-miss, and instead places blame on all other members present, as he believes that checking patient notes for confirmation prior to the procedure is the responsibility of anyone but himself. The atmosphere in the operating theatre would likely be tense not only for this procedure, but for any procedure where Mr. Jones is present. Thus, this tense atmosphere may distract other members of the surgical team, taking their focus away from patient safety, and instead on performing the surgery in such a way that doesn’t upset Mr. Jones, leading to a similar outburst. The distracting presence of Mr. Jones may unfortunately lead to worse outcomes for patients during/after surgeries. I would like to see a more forgiving and understanding culture develop in the surgical theatre, as the responsibility for the near-miss should be shared across all members present, including Mr. Jones and other healthcare professionals with similar attitudes.
    2. Other errors include:
    Dr Patel forgetting to wash her hands after checking a patient with an infection, thus transmitting it to Jane, as she was distracted due to the stress she faced earlier in the day. This could have been avoided by checking the attendance for the post-op care briefing, noting that Dr Patel did not attend and then making sure that the information shared in that briefing somehow makes it to Dr Patel (i.e. through giving her an information handout)
    Dr Patel forgetting to record Jane’s wound infection in the patient notes for the F2 doctor, Dr Lynch, meaning that Jane is discharged despite still having an infected leg wound

  132. Anonymous says:

    1. The apparent culture in the operating theatre seems to be one of a hierarchy of which creates an uneasy atmosphere for those who do not feel as they are as high up. Nurses and less experienced doctors appear to feel as if they’re in an environment of which they cannot speak up and if they do that this will either be ignored or received badly. Leading to a lack of communication between the team, and creating environments where only the more senior people in the room make the decisions. However teamwork requires input from everyone and everyone’s opinions and ideas should be listened to without judgement just because they may not be the most senior in the room. Furthermore, having a good and healthy attitude towards one another is needed to allow people to feel this inclusion. Therefore as a senior medical professional in the team, people will automatically look to you for guidance in situations and hence their attitude can dramatically influence the situation. Hence everyone in the team and especially those of more experience should look to be guiding characters who set a good example for communication and team work.

    2. Other problems in Jane’s care involved the transmission of bacteria to the wound and the handover between the two F2 doctors. The correct hand hygiene may have been used if the F2 doctor was in a clearer state of mind, which again could be prevented through a more positive team working environment. Furthermore, the antibiotics were forgotten and not put on the list of jobs for the next doctor taking over Jane’s care. Although this may be a mistake and one of which was not intended to happen, it can have severe consequences for Jane and her recovery. One way this could be avoided is a physical hand over between the two doctors where Jane’s condition is discussed between them. This may also help to jog the F2’s memory about the antibiotics when handing over which could decrease the chance of something being forgotten. Dr Patel not being aware of the hospital policy change is also a vital problem, clearly the new policy did not reach her, finding the root cause of this is key, for example if it was sent via email then it’s important to be aware that not everyone may have seen it etc. Briefing people in person about the policy change would be a way to try and prevent this.

  133. Anonymous says:

    1. The culture in the operating room was such that there was a clear hierarchy, with Mr Jones the consultant at the top. He believes himself to be superior to the others present and does not easily accept suggestions or criticism. There is also a culture of fear among Dr Patel and the other more junior members of staff that leave them too afraid of Mr Jones’ reaction to point out mistakes until it is almost too late. Finally, a culture of blame leads Mr Jones to immediately start reprimanding his team rather than thanking them for pointing out the near miss and considering how this happened in order to ensure that it is not repeated.
    2. There were several subsequent problems with Jane’s care. Firstly, Dr Patel was clearly shaken by what had happened in the operating theatre and so was distracted. She could have avoided making mistakes with Jane’s care if she had taken a moment to collect herself so that she was in the right frame of mind to continue treating treating patients. There were also mistakes made in communication between the two FY doctors. Mistakes could have been avoided had the changes in infection protocol been communicated to Dr Patel after she missed the presentation, and had Dr Patel taken the time to properly document the infection before going to see the next patient.

  134. Anonymous says:

    1) The operating theatre appears to be an environment controlled by the lead surgeon. Despite the presence of many different healthcare professionals, they are not working together in the multi disciplinary team. There is definitely hierarchy present where others do not feel comfortable raising concerns. This environment should become more open and policies put in place so that no consequences come from raising a valid concern.
    2) Due to Dr Patel’s distractions many protocols are missed. Firstly, correct hand washing procedure is not followed after an examination which leads to Jane developing an infection. Also Dr Patel should have made it a point to read up on or seek clarification on the hospital protocols that she could not attend. This would have meant that Jane was treated quickly and efficiently, in line with how all other patients are treated. Also Dr Patel moves on to the next patient without properly rounding up the care of Jane. This increases the liability to forget to return to Jane and ultimately leads to the next F2 on shift prematurely discharging Jane without the proper care that she needs. Dr Patel’s mistakes stemmed from her distraction from how she was treated in the operating theatre this morning. The surgeon should not have treated her this way, but also Dr Patel should have recognised her distraction and put it out of her mind before moving to treat other patients on the wards.

  135. Anonymous says:

    1. The atitude of the senior doctor towards the other health care professionals, the lack of open communication, the leadership skills of the surgeon, the lack of team spirit.
    2. The fact that she got an infection because the negligence of the junior doctor, the lack of proper communication between the two FY doctors, the fact that she is to be discharged while having a very bad infection that needs treatment, the fact the infection control protocol has not been made widely available to all the doctors in that hospital and, subsequently, has not been put in place. These aspects could be rectified by a more careful approach of the hospital team towards patient care.

  136. Anonymous says:

    Jane’s story episode 4 :

    1. Please comment on the apparent culture in the operating theatre. What would you like to see change?

    Within the theatre there is a clear hierarchy – the surgeon is the boss and cannot accept he is to blame I this situation to. Instead he seeks to blame and verbally punish others in the team, for not speaking up earlier, for not noticing or for marking the wrong leg. Rather than focusing on fixing the problem at hand, he focuses on punishing others for not noticing the mistake earlier, when he himself didn’t notice the mistake either. This fear and blame culture in the operating theatre is what made other staff hesitant to point out the mistake in the first place, and his lack of compassion and angry attitude exacerbates this. The surgeon is confrontational to other staff, so they fear him, this causes communication problems within the team. The surgeon’s attitude makes other staff feel fearful of him, and also he belittles them and knocks their confidence in themselves. Whilst this is detrimental to people’s mental wellbeing in the workplace, ultimately patient’s will suffer.
    The other staff should have support, a person to turn to if they feel they are being bullied I the workplace, and a person of appropriate power over all the staff should be able to take action in stepping into the situation and talking to a member of staff causing issues. Perhaps the surgeon has issues causing his anger, outside of the workplace and is affecting his work / attitude. The surgeon himself should be offered appropriate support to help him change his attitude, maybe take some therapy to help him manage his anger in the workplace, this will improve team morale and improve the outcomes for everyone.

    2. What subsequent problems can you identify in Jane’s care and how could they be rectified?

    Dr Patel was publicly humiliated by the surgeon in front of the team, and so she feels upset and embarrassed. This has affected the care she delivered for the rest of the day. She is distracted because she was scared, consequently she forgot to wash her hands after touching first infected patient, unintentionally contaminating Jane’s wound with the bacteria from the previous patient. This will cause avoidable suffering for Jane as a result of dr Patel forgetting to decontaminate her hands between patients.

    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. Dr Patel was unable to attend and so is unaware of this protocol. Seeing the consequences that this had on Jane, any new protocols in the hospital should be made compulsory to attend – ensuring everyone is on the same page for treating patients. Furthermore, before she can write a note to the F2 taking over her shift, she is taken away by a nurse to look at another patient. And so Dr Patel leaves the hospital once her shift is over, having forgotten about the note to notify the F2 taking over about Jane’s infection and plan of action for treatment.
    This means Dr Lynch is unaware of looking over Jane’s leg before discharging her, and because her husband is waiting on Jane to collect her, perhaps she feels the pressure to discharge her asap without properly checking her over. Dr Lynch should have checked her leg post surgery before discharge anyway just in case. But. Because she didn’t check Jane before discharging her, the infection will continue to brew at home where she won’t be in an environment surrounded by doctors, and so she will be put at risk.

  137. Anonymous says:

    1. The operating theatre has a senior surgeon who feels he is superior to the more junior staff and blames them for any mistakes made in the room. There is a blame culture and due to the attitude of the surgeon, many staff feel unable to speak up about concerns without being embarrassed publicly. The culture should change to become a more open environment where all the staff feel they can communicate and raise concerns if needed. If the team members are able to communicate openly then the patients are far safer and mistakes are less likely to be made due to the good multi disciplinary teamwork.
    2. Problems in Jane’s care include that the doctor has contaminated her wound. If Dr Patel had washed her hands before redressing Jane’s wound this wouldn’t have happened but she was distracted by Mr Jones shouting at her earlier that day. Jane also didn’t get antibiotics in the hour due to Dr Patel not attending the meeting about the new hospital protocol about wound care. Then in the handover the note Dr Patel made about how Jane will need antibiotics was missed and Jane was discharged. So the surgery environment must change to avoid staff feeling humiliated and embarrassed after raising concerns so they won’t be distracted the rest of the day. If a doctor misses an important hearing they must learn all of the information they missed, and take all steps to not miss anymore important information. Patient notes must be checked thoroughly in handovers.

  138. Anonymous says:

    1) the culture in the operating theatre is one where medical staff feel uncomfortable and scared to raise any potential concerns.There is also a blame culture where the surgeon seeks to blame and reprimand anyone who was involved in the mistake. I think it would be good to have a more relaxed atmosphere, in that all members of the medical staff feel comfortable enough to raise any concerns, this will help prevent any more near misses or mistakes. I think it would also be good to instead of seeking to blame others for a mistake but to look at the situation as a lesson- to learn how an incident could be prevented in the future.

    2. The further errors in janes care were the poor hygiene of Dr Patel, transferring bacteria into janes wound, Dr Patel not knowing hospital policy, and also communication. If Dr Patel had written a note for the next F2 doctor before exam ing the other patient the error could have been avoided. Also Dr Lynch overlooking the entry in Janes notes lead to the infection being missed. The mistakes could be rectified by Dr Patel ensuring she always washes her hands after and before dealing with a patient, and by Dr Lynch taking n the time to read Janes notes correctly.

  139. Anonymous says:

    In the operating theatre there is a hierarchy which has made the nurses and junior doctors under confident in speaking up to the senior surgeon. There isn’t an emphasis on the entire team working together to ensure the best patient outcome, instead the surgeon in charge instils fear in the other staff, so much that they do not speak up as they are scared of being wrong. The environment is tense which has created communication barriers between the staff. Overall communication needed to be improved, improved communication between the surgical staff, between the F2 doctors, between the staff regarding new regulations and also with Jane herself.
    I would like the communication between the staff to be more appropriate so that every person in the room, regardless of superiority or job, feels free to speak their concerns. This will improve patient safety by making the patient the priority. I would like to see the team work improve and the senior surgeon should act as a more effective team leader. He should do this by not by placing blame, but by working with his staff to improve their mistakes. If someone does make a mistake, they shouldn’t be humiliated or reduced to tears, the mistake should be analysed by the team to ensure it doesn’t happen again. When problems arise, they should be dealt with calmly and professionally which will help create an. open environment
    There where multiple problems in Janes care in this episode. Dr Patel forgot to wash her hands after touching her previous patient and before touching Jane as she was distracted due to the angry Mr Jones – hence the infection spread to Jane’s leg. Dr Patel didn’t appropriately record the infection in the notes so Jane was discharged without the next F2 being aware of the infection. Thereupon, Jane’s infection in her leg will only get worse at home – this will put her leg and life at risk. Dr Patel should have been made aware of the protocol she missed so she could learn the new rules regarding antibiotics. These mistakes could have been rectified by multiple ways. If Dr Jones wasn’t so angry about the mistake before surgery, perhaps Patel wouldn’t have been so distracted and remembered to wash her hands. Dr Patel should have written the infection down in the notes before seeing the next patient to ensure that the next F2 was aware of Jane’s infection.

  140. Anonymous says:

    1. There is a culture in the theatre where the staff is afraid to speak up about concerns that may impact patient safety. This is due to the fear of being scolded by the surgeon. He has a very negative attitude towards his more junior colleagues which intimidates the whole team. This approach to practice does not promote good team morale. I would like to see an environment created where ‘near misses’ are not met with anger, such as in this situation, where the younger doctor felt humiliated afterward. Instead, I would like to see an environment where instances like this are recognised as being potentially dangerous but are used as examples to learn from so the same mistakes are not repeated. These instances should be used to investigate potential gaps in training or areas where protocols need updating to ensure mistakes in practice are minimised.
    I would also like to see a change in the attitude of the surgeon. Senior staff should be encouraged to promote honesty, so speaking up about safety issues is not feared. This will ensure patients are not put in danger. He should encourage his team and support them in their professional careers. All members of the team would feel valued and supported, promoting a positive environment.

    2. The harsh attitude of the surgeon towards the junior doctor resulted in them being distracted and ‘put off’ their work. The correct hand hygiene procedure was not carried out and Jane’s wound became infected. This would have been less likely to occur if senior staff had a more positive attitude towards other staff.
    Furthermore, the doctor was not aware of the new protocol and should have taken the time to find out what information they missed at the meeting. The hospital should ensure staff is made aware of new protocols and ensure the information is received. This would have prevented the delay in Jane’s treatment.
    A break down in communication between the doctor and the F2 coming on shift has resulted in Jane being discharged with an infected wound. If left untreated, this could cause more serious problems for Jane and further delays in the healing process. This along with the other mistakes made in her treatment will further damage her trust in the medical profession. Patient care has been compromised in this situation and the infection should have been recorded immediately in Jane’s notes to prevent this from happening.

  141. Anonymous says:

    As in most, there is a clear hierarchy present in this operating theatre. However, the apparent culture disallows effective communication and free expression of ideas and concerns which ultimately is to the detriment of the patient. The problem is not that role hierarchy exists, but rather that Dr Jones feels his position allows him to look down on other members of the surgical team and disregard their opinions, sounding off when a potential error is identified. This leads to Dr Patel feeling embarrassed and upset which, as we read, goes on to affect her performance later on in the day. This is not only an example of bad teamwork, but it also highlights how ineffective cooperation between medical staff can have consequences, not limited to the immediate patient being seen to. (Although in this case, it happens to be the same patient adversely affected.)
    I would like to see better teamwork within the surgical team and better leadership rather than dominance, from Dr Jones. Furthermore, the medical professionals should devise methods of communication in such a way that if something is urgent every member of the team understands, and the patient will not be alarmed. Although I am assuming Jane is already anaesthetised when sister Higgins shouts ‘STOP!’ had she not been, this would have undoubtedly worried her.

    The poor communication within the operating theatre really paved a path for subsequent errors in Jane’s care. As her mood was offset, Dr Patel is distracted and begins to make errors such as forgetting to wash her hands which leads to contamination of Jane’s leg. Dr Patel was also absent during a time at which post-operation wound infection protocol was changed meaning she is unaware of the new regulations. When briefings for protocols such as this take place, there should be a means of communication so that those unable to attend are made aware of any changes. Dr Patel being called away mid-task to complete another task is unavoidable however is essentially a latent error, and by forgetting to speak to the F2 doctor, Jane, along with other medical professionals, is unaware of the infection. Overall, the biggest problem in this situation is the lack of communication between the medical professionals themselves, but also with Jane. Unless absolutely unavoidable, handoffs should not occur via notes written on pieces of paper. If Dr Patel and the F2 doctor had communicated directly, there is a high chance the necessary information would have been conveyed.

  142. Anonymous says:

    Staff in the operation theatre are afraid to speak up and hesitant to voice their thoughts out of fear of being reprimanded by their superior. It appears that the surgeon is the superior and his negative attitude and impatience discourages people from voicing their doubts. The environment is not ideal, as Dr Patel and Sister Higgins got belittled in front of their colleagues, as he loudly shouted at them. What should change is that doctors, nurses and staff should try to be calmer, even if they are tired or frustrated because if they get annoyed or flustered, it will cause mistakes to occur and their working relationships with those around them to deteriorate.
    There are numerous issues with Janes care, the first being poor communication between medical professionals with each other and with Jane herself, leading too many unnecessary mistakes and a lot of problems that could have been avoided. Another major issue, is staff being too distracted to follow proper protocol or look at the finer, minute details which hold a lot of importance. In this case it was Dr Patel forgetting to wash her hands. For things like this to be rectified, the working relationships with medical professionals should improve and there should be better more effective communication, important details should never be passed over to the next shift by just notes, staff have to verbally communicate them. Stricter measures when it comes to following proper protocol should be enforced, like when it comes to washing hands.

  143. Anonymous says:

    1.There appears to be a hierarchy in the theatre as Mr Jones was condescending and extremely unprofessional as he focused more on who caused the mistake rather than how he can fix it and was rude to the nurses and other members of the surgical team which as seen from the rest of the episode could affect their confidence and focus for the rest of the day which in turn could cause more mistakes with other patients and again endanger them. There should be a more calm and understanding environment where the head surgeon doesn’t bully everyone and where everyone can speak freely. This not only would prevent mistakes like this 1 but would also result in the skills of those involved develop as people could learn from each other.

    2.There has been severe communication issues in Jane’s care along with hygiene issues as Dr Patel didn’t properly wash her hands when she treated Jane. To rectify these Dr Patel should have either finished her treatment on Jane and informed someone else about the issue or if seeing the other patient was time sensitive should have written a note for herself. Furthermore Dr Patel should have tried to keep focused even after dealing with Mr Jones as it would mean she wouldn’t have forgotten to wash her hands. Finally the hospital should have forwarded the information that Dr Patel missed as to ensure all staff members followed the protocols to keep the patients safe

  144. Anonymous says:

    1. The staff in hospital feel anxious and unable to speak up out of fear of the backlash they may receive from the surgeon or others with more authority. I would like to see changes here allowing all staff to be able to speak out if they have concerns about patients, staff or themselves as this would be most beneficial in assuring patient safety and overall safe practice. The surgeon also has a generally bad attitude with a bad temper and the belief that he is ‘superior’ to others. If the surgeon communicated better with the other staff by using a calmer tone of voice and listening to their opinions, it would create a better and safer working environment.
    2. Firstly, Jane became infected due neglect of hygiene by Dr Patel. Doctors should ensure they wash or sterilise their hands before and after examining each patient to prevent spread of infection. Dr Patel was also unaware of the new protocol on infections which would have a negative effect on Jane’s health and recovery. This could have been avoided by ensuring all doctors attend important protocol meetings before going out on the wards and therefore no doctor will enter the wards unaware of the correct guidelines on treating patients if these meetings are compulsory. Another issue is that Dr Patel failed to make the next doctor aware of Jane’s condition and the necessary treatment. Dr Patel should have finished Jane’s notes to inform the F2 doctor before she moved on to assess the next patient or upon noticing she had forgotten, informed the F2 doctor immediately. The F2 doctor should have also checked notes more carefully so Jane was not discharged.

  145. Anonymous says:

    1. The culture in this operating theatre is one where the surgeon feels that he is superior to the rest of the staff. However, this atmosphere will not result in optimum patient care as teamwork is key to a successful operation. The surgeon’s attitude is discouraging the staff from speaking up about potentially disastrous errors and his humiliation of junior colleagues may put them off specialising in this particular field or even continuing their career with the NHS. His treatment of Dr Patel also clearly distracted her from her work for the rest of the day. He belittled her in front of colleagues and took no responsibility for an error which he himself could also have taken steps to prevent.
    2. Dr Patel neglected simple safety precautions such as hand washing and this had disastrous consequences, leading to an infection in Jane’s wound. Dr Patel was also not up to date on the latest protocols. She should have taken the initiative to catch up on the information she missed in the briefing. Moreover, the handover to the F2 doctor was poor. Dr Patel should have recognised the seriousness of the infection and taken the time to ensure it was clear in the patent’s notes. However, no record was made and now the F2 doctor may unwittingly discharge Jane despite having an infected wound. This was a huge lapse in communication.

  146. Anonymous says:

    1. A hierarchical system seems to exis that discourages people to talk and raise their concerns when they feel they need to. Also, there is a lack of teamwork and people are blaming each other instead of sharing responsibilities.
    I would like to see an operating theatre where;
    – all staff are treated and respected equally.
    – staff communicate efficiently and have patient’s safety as their main priority.
    – no “blame” culture is present and all share responsibilities when needed.

    2. Problems identified:
    – Dr Patel infected Jane and this might lead to further complications
    – Lack of communication between Dr Patel and F2 doctor
    These could be avoided if Dr Patel took a few minutes to calm down before she moved on to the next patient. In addition, she should not blaming herself and feeling embarrassed for the previous incident, at least she talked to the sister and told her to check the notes and by doing this she avoided a terrible mistake to happen. Also, she should remind herself that every patient deserves her focus and attention so she must have a clear mind before seeing a new patient. It is okay not to be okay sometimes so she could even have asked a colleague to go and see the patient if she was still feeling upset.

  147. Anonymous says:

    It is crucial that all members of surgery team work together, bring together their knowledge to provide best patient care. All members of the team should feel as though their knowledge is valued and feel comfortable speaking up if they see any issues. It is apparent that an open environment for discussion has not been developed, created by members of the team feeling superior and then putting blame onto others when problems arise. Mr Jones humiliation of fellows colleagues creates a tense environment, where other professionals feel uncomfortable speaking out.
    2.there is lack of time taken through the patients care, and problems have arose due to lack of through examination of Jane. Dr Patel made assumptions about Jane’s pain instead of completely a proper examination and investigating all the problems. There is lack of proper hygiene by Dr Patel.Dr Patel should have made a note to go back to Jane and also not being update with hospitals protocols. A lot of this issues could have been prevented with better communication and more take taken for the patients care.

  148. Anonymous says:

    1. It is evident that Mr Jones, the surgeon, believes he is superior in the operating theatre and therefore sees fit to berate the other theatre staff. This should change as, when in the operating theatre, teamwork is crucial to ensure a safe surgery and maximise patient outcome. If this hierarchy is allowed to exist, it will leave staff feeling upset and anxious before, during and after surgery. This could compromise patient safety. Furthermore it will damage the mental health of the theatre staff, as evidenced by the junior nurse having to leave the operating theatre after Mr Jones’s angry outburst. All members of the surgical team should have more respect for each other and deal with situations calmly and respectfully. This was not the case with Jane’s ankle surgery.
    2. There has been an error in communication with Dr Patel after she gets distracted. In order to have this rectified Dr Patel should have finished recording her notes before moving to assess the other patient. Failing this Dr Patel should have made a brief note to remind her to return to Jane’s notes. This would have prevented the inappropriate and unsafe discharge. There was also a problem in terms of Dr Patel not being up to date with hospital protocols. If it was not possible for her to attend the hospital infection protocol briefing, she should have made note to find out about the briefing as it did contain important information. This would have guided her treatment of Jane’s infected wound and she perhaps would have taken more immediate action.

  149. Anonymous says:

    1. In the operating theatre doctors and nurses feel unable to speak up to query or clarify issues for fear of being wrong. I would like to see change in that the operating theatre becomes an open environment rather than an environment of fear and that it becomes a place where questions are welcomed, rather than dismissed and discouraged. I also think it would be good if there was no humiliation, as this would reduce the fear of speaking up and ultimately protect patient safety.
    2. Subsequent problems in Jane’s care include the lack of a thorough examination by Dr Patel of what is causing Jane pain. Instead of examining the wound and considering a range of causes for pain, Dr Patel assumes it is due to the bandage being too tight. Furthermore, Dr Patel’s poor hygiene, which includes forgetting to wash her hands causes Jane to develop an infection. Other problems in Jane’s care involve Dr Patel not actively finding out about the new protocol that was administered, resulting in antibiotics not being administered to Jane when the infection was first discovered. In addition, forgetting to record the infection in Jane’s notes, as well as Dr Lynch’s overlooking of the last entry in Jane’s notes results in Jane being discharged despite her developing infection which should’ve kept her in hospital. Many of these mistakes could’ve been avoided by taking more time and care with patients, remembering hygiene rules, taking account for all possible reasons for pain, keeping up to date with new protocols in the hospital and writing up patient notes as soon as possible. In addition, these mistakes could be rectified if Dr Patel checks what happened to Jane when she is on her next shift and realizes her mistake.

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