Incident and Investigation of a Patient Underwent General Anesthesia: Consequences and Probable Remedies to overcome the lacunae.

Assignment title: Incident and Investigation of a Patient Underwent General Anesthesia: Consequences and Probable Remedies to overcome the lacunae

Declared word count: 2245

Professional reflective practice is a way of studying our own experiences to aid our professional development continuously. Helping the health care practitioners to improve their confidence and become a more proactive and qualified professional (Brown and Ryan 2003).
As a part of preoperative procedure, the general or local anesthesia will be given to the patient in order to facilitate the surgical procedures. The duration of operation and the surgical procedure to be performed dictates the type of anesthesia. In the current case, the patient was undergone for general anesthesia that allow the patient to undergo a reversible unconsciousness, loss of sensations due to prevention of nerve impulse conduction, paralysis of muscles and sedation. The administration of two or more anesthetic agents in general anesthesia requires close monitoring of the patient for secondary stimuli of pain, symptoms of memory, respiratory functions and cardiovascular functions (ADA 2012). The muscle relaxants can also be administered along with the general anesthetics in order to allow the muscles to relax (Brull & Naguib, 2009). The anesthesia will be provided under medical supervision and shall be closely monitored.
In the current case, the patient was administered with an anesthetic agent. Due to lack of adequate communication from the healthcare team, the patient underwent severe adverse events such as big amount of vomiting causing pulmonary aspiration (The entry of food or drink, or stomach contents from gastrointestinal tract into the lungs) and collapse of the lungs. An incident was prepared for the situation, and an investigation was carried out. The present assignment describes the guidelines and ethical considerations for general anesthesia; nursing care and communication; checklist for surgical safety; food effect on aesthetics; investigation; possible remedies to overcome the lacunae followed by conclusions.

Guidance and Legislation
The pre-operative care is the whole responsibility of the team comprising professionals from diverse departments that include nurses, anesthesia, physician, surgeon and pharmacist (Jones et al. 2014). The hospital should follow certain legislation and guidelines for administering anesthetic agents and care for the post-administration of anesthetic agents. The health care team should create an environment to establish a rapport with the patient and gather the standard information; diagnose the patient for the disease to be treated, identification and management of safety issues relevant to the individual patient. A pre-operative assessment is required for most patients who undergo a surgery (AAGBI 2010). The objective of the pre-operative assessment is to design a plan and deliver an optimum and safe anesthesia in order to understand the importance of the risk. The pre-operative health care facility and anesthesia play an important role in ensuring collaborative decisions. The pre-operative procedure is a process where the healthcare professional and patient work together to select tests, treatments, and management of anesthesia based on clinical evidence and the informed preferences of the patient. Based on the outcome of the diagnosis, the anesthesia decides that the duration of anesthesia to be maintained. In the current case, the patient is subjected to preoperative assessment by an anesthesia registrar and they decided to be the general anesthesia is the appropriate plan for surgery. The patient was also agreed to the plan. The clinic should provide the collaborative decision throughout the patient journey.

Ethical considerations
The members of the American Society of Anesthesiologists are dedicated members for the implementation of the ethical provisions of health care. The society recognizes the principles of medical ethics of the American Medical Association as the basic guide to the ethical conduct of its members (ASA 2003). The following are the ethics to be considered during anesthesia
Anesthesiologists should respect the rights of every patient in terms of self-determination. The anesthetized patients are particularly vulnerable. The Anesthesiologists should strive an intensive care for each patient in terms of physical parameters and psychological safety, comfort and dignity. Apart from these considerations, the Anesthesiologists should also monitor themselves. They should extend the monitoring towards their colleagues to protect the anesthetized patient from any abusive behavior. The anesthesiologists should not disclose the medical and personal information to unauthorized persons. The anesthesiologists should also have ethical responsibilities towards medical colleagues in terms of cooperation and respecting their decisions. They should cooperate with colleagues to improve the quality, effectiveness and efficiency of medical care. From health care facility perceptive, the anesthesiologists should serve the facility and provide attention towards special committees. The skills for competence should be increased themselves as a part of their professional practice. They shall recognize the responsibility to participate in activities contributing to an improved community. In the current case, the anesthesiologist respect the decision of the patient and the patient also agreed to the surgical procedure.

Nursing care and communication
The nurses are the one of the integral part of multi-disciplinary peri-operative care team. The nurses shall be well educated, trained and skilled in terms of communicating the vocabulary to the patient (BARNA, 2012). They should be professionally competent enough to manage the work. Technicians also should be strong enough to understand the symptoms of the patients and to record them in the case sheets. They should communicate the symptoms time to time to the doctors. The nurses shall maintain a clear written lines and verbal communication. The verbal communication plays an important role in conveying the message to the patient and understands the problems for patients. The nursing services should be in such a way to create an environment so that the patient shares voluntarily their problems with the nurse and thus doctor. In the current case, the nurse was able to speak English and few words of Arabic with poor ascent. The patient does know only Arabic. As a part of preoperative procedure and orders from the anesthetic registrar, the nurse was informed the patient to be fast. The patient understands in a different way that she was conveyed that he had to be fast from the night to till surgery. He was taken food in the next day before the operation. The discrepancy, in understanding the instructions from the duty nurse, is due to lack of adequate communication. The presence of the translator could have solved the discrepancy. Unfortunately, the hospital does not provide a translator to translate the message from the nurse to patient or problems of the patient to the nurse. The hospital trusts that the nurse will deal with the patient in communicating the message. The readout from the case study is that the nurse communication must be appropriate to the individual patient, career and delivered in clear, understandable language. It is also important for the nurse in order to communicate the significant adverse events from the patient immediately to the anesthetist. In the pre-operative procedures, the operating room nurse will receive the patient’s details from the ward nurse along with the patient into the operating room. Then the anesthetist will document the events during the anesthetic period in either written or electronic form, to be attached in the patient’s file.

Surgical Safety Checklist
A surgical checklist can be prepared before induction of anesthesia; initiation of surgical procedure and post surgery (WHO, 2009). The surgical checklist consists of three parts (i) before induction of anesthesia, the nurse and the anesthesia team are responsible to fulfill the checklist; (ii) before skin incision, the nurse, anesthesia team and surgeon are responsible; and (iii) before the patient leaves the operating room, the nurse, anesthesia team and surgeon are responsible to complete the checklist. The parts of the checklists contain questions like, “Has the patient confirmed his/her identity, site, procedure, and consent? Is the anesthesia machine and medication checking complete? Is the pulse oximeter on the patient and functioning? Difficult airway or aspiration risk? Has antibiotic prophylaxis been given within the last 60 minutes? Any critical events are anticipated by surgeon/anesthetist/nursing team?” The questions should be answered by using the terms ‘yes’ or ‘no’ with proper justification. In the current case, the first part of the checklist was completed before induction of anesthesia.

Adverse events due to non-fasting state anesthetic procedure
In the current case, unfortunately, the anesthetist started the initiation of anesthetic agent without confirming from the patient based on the written statement from the file, i.e., ‘fasting’. The anesthesia should be given to fasting the state to avoid vomiting and adverse events (Arlachov and Ganatra, 2012). To facilitate the surgical procedure, a part of the anesthesia medications such as muscle relaxants will be given. Sometimes more than one anesthetic agent will be given to induce and continue the anesthetic effect. Since the drugs are multiple, may result in showing adverse events. However, there exist certain drugs that overcome the respiratory distress during general anesthesia (Elwood et al. 2003). In the current case, after administration of muscle relaxant, the patient started vomiting, and a big amount of food were aspirated. The medical team tried to manage with the suctioning and performing a lung lavage (lung washing). Due to forcibly vomiting of the gastrointestinal contents that include food and gastric juice, the lungs of the patient appears to be compassed. It further results in difficulty of an airway passage and affects the respiration/aspiration process. The anesthetist and surgeon had canceled the operation and order the nursing staff to transfer him to intensive care unit and further the patient was ventilated. The status and function of lungs were collapsed due to the big amount of aspirate especially in the right lung. It was evidenced from the chest x-ray. The difficult of airway in terms of managing the passage is main concern for the patients who are undergoing for anesthesia. In some of the patients, it could lead to morbidity and mortality, for this reason close monitoring is required during anesthesia (Carin et al. 2005). Certain anesthetic agents affect the central nervous system and cardiovascular system and respiratory systems in a dose-related manner. Such anesthetics cause adverse events by inhibiting the neuronal reflexes and thus decreases the levels of consciousness and depression and may cause cardio-respiratory failure (Berthoud and Reilly 1992). The inability to secure the airway in its native form led to the deficiency of oxygen supply. It eventually led to the failure of oxygenation and ventilation. The situation is a life-threatening complication because the oxygen supply would be decreased and ceased to major organs such brain, kidneys, and heart (Adnet 2000). The patient may die in such situation.

Incident Preparation and Investigation of the case
An incident report was prepared immediately on the situation, and an investigation was carried. The case was investigated in order to understand the reason it happens. The investigation started from the registrar anesthetist. The registrar instructed correctly and written in the file to keep the patient ‘fast’ as one of the order. The ward nurse was also conveyed the same thing to the patient. Finally, the investigation reveals that the message was reached the patient, but in a different way. The nurse on duty conveyed the message in English ‘should be fast’ and a few unclear Arabic words ‘lazem soom’. The patient understood with a different meaning. In the investigation, the patient was expressed that the nurse had told him “you have to be fast from midnight till the surgery time.” In addition, he was not aware of the consequences of doing that. Neither the nurse or the anaesthetist explain to him the consequences. Next day, he had taken a stomach full of breakfast and prepared for the surgery. Due to language constraints the patient did not ask the nurse pertaining to his doubts, i.e., how long I should be in fast? When should I take food?.

Focusing on the lacunae
From the investigation, it was understood that the whole situation was due to adequate communication. The communication can be considered as the major lacunae for this reason; the communication skill should be improved. In addition, the consequences of the anesthetic agents were not explained to the patient. The consequences in terms of vomiting are required for the patient to understand the adverse effects of drugs. For this reason, the nurses and other paramedical health staff should be trained for the pharmacological actions and adverse events of drugs. In emergency situations, the skills would help the health care staff member to save the life of patients (Tourangeau et al. 2006). In addition, the skills are important as leadership skills in addressing some of the failings (Kerridge 2013). The improvement in social skills will help the nurses in understanding the psychology of the patients (Seo et al. 2013). The hospital should provide training facilities to the nurses and other health care team. The skills include communication, technical and regional to understand the translations from the doctor and problems for the patients. The technical skills would help in understanding the significant changes during the treatment and conveying them to the doctors. The nurses who do not know the regional languages, the hospitals should provide translators for the conversation.

Conclusions
An investigation was carried out on the patient why he was shown such adverse event (vomiting), and an incident report was prepared and submitted. The series of events is due to lack of adequate communication to the patient. The health care team and patient everyone understand in their way, but the actual message ‘to be fast’ has reached the patient in a different way. To avoid such circumstances, the hospitals should provide training to the health care practitioners who might be involved in the preoperative assessment in order to improve the skills. In addition to that the correct documentation according to the WHO checklist would avoid the discrepancies.

References
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