What patient safety issues does this case study highlight?
A 60-year-old female patient, Mrs Teuila Afualo, presents at the day surgery unit (DSU) for an open repair of an umbilical hernia at 8 am. She is of Islander background and has brought several of her family members with her. On admission, you calculate her body mass index (BMI) to be 38, note that her respirations are shallow and rapid, and that she appears to be extremely anxious.
Her medical history highlights that she has type 2 diabetes, which is managed with metformin, although she tells you that she has not been diligent about taking or recording her blood glucose level (BGL) regularly. She also informs you that a ‘couple of months ago' her GP prescribed tablets to treat her cholesterol and her blood pressure but she can't remember the names of them, and her son doesn't know them either. She has not taken any of these medications prior to her admission, her reason being that she was fasting. Her BP is 160/90 mmHg and her fasting BGL is found to be 12 mmol/L.
You also identify that Mrs Afualo did not attend the preadmission clinic. She explains that she could not attend because her son was not available to drive her. Consequently, she has not had a preoperative chest X-ray (CXR) or any blood tests as per her surgeon's protocols. A check of Mrs Afualo's consent form in the presence of her son reveals it has not been signed and that she is somewhat confused about her intended surgery.
What will be an ideal response?
Answer:
Because Mrs Afualo had no means of transport and thus was not able to attend the preadmission clinic, she did not undergo the normal preoperative workup and review that are required for surgical patients. Consequently, Mrs Afualo did not have the necessary tests completed (e.g. CXR, blood tests), nor was there opportunity for her or her family to be provided with important preoperative education (e.g. the importance of taking her medications, including on the day of surgery). Consequently, Mrs Afualo was not properly prepared for her hospital experience.
On arrival at the hospital, Mrs Afualo was in a state of great anxiety. This is not a desirable state for any perioperative patient, as it adds to the overall burden of stress associated with surgery.
The incomplete consent form needs to be addressed and in the current situation, and given Mrs Afualo's anxiety, there is a chance that she may feel coerced into signing it. It is important that her son remains during the surgeon's visit so that he becomes fully informed (given his mother's anxiety).
There was no preoperative anaesthetic review. This activity is important for all patients, but particularly so in the case of patients who, like Mrs Afualo, have co-morbidities.
The family were unaware that limitations on visitors would be enforced. There is often opportunity for only one family member to remain; and, in some instances, no family members may remain with the patient. This depends on the hospital protocol.
This is a safety issue because the presence of several family members reduces the space and freedom of movement around the bed for nursing staff. Their presence also impedes access for other staff e.g. physiotherapists, radiology technicians and so forth. Large numbers of visitors in DSU can cause tension with staff and other patients and anxiety levels of all can be increased. Noise levels can also become unacceptable when there are too many visitors present.
(It is also an issue when the visiting surgeon wishes to discuss the patient's procedure with them and everyone has to leave or are spoken to as a group when perhaps this is not what the patient wants.)
Mrs Afualo completes all the preoperative tests and her family stay with her until she is taken into the operating room. Her surgery goes well and she makes an uneventful recovery. Once she is transferred to the stage 2 recovery area, her family are allowed to see her and to remain with her. Her vital signs are stable, and her BGL is noted to be acceptable. Consequently, Mrs Afualo is allowed to eat and to begin preparation for discharge home.
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