Description
The incident I will be reflecting on occurred whilst I was working an operation theatre during my work time. We had so many cares each day and after surgery they might be body tissue specimen for histopathology testing for histopathology body tissues are normally sending to laboratory after labeling each patient. The circulating nurse will take the responsibility for doing this work. On the day of incident the assigned surgical nurse handed over the tissue specimen to the circulating nurse. My role was the scrub nurse and the surgery was laparoscopic ovarian cystectomy. After surgery I handed it over to the concerned nurse and she put the label of the patient. Immediately, she sent the sample to laboratory. After some time the laboratory technician called regarding the sample. He received two samples with same patient label. The error was happened while placing the patient label to the bottle. We went to the lab, identified the specimen and corrected the patient label because our sample was with the wrong patient label. Managed the situation in a proper way and the problem was solved.
Feelings
Prior to this incident, the handling of body tissue specimens didn’t find any problems as same as this. Everybody in the department as very active, alert and everybody will do repeated checking. The incident day was a busy one and everybody was busy on their works. On that day we were failed to do a cross checking due to busy schedule. Before sending the samples to the lab we will show it to the relatives and patients. Unfortunately when we were showing the specimen to the relatives we forget to put the label on the bottle. Even if we put the label on that time, I can rectified the problem and it won’t happened I was under increased level of anxiety and stress because this will make change in the treatment plan for the patient. After this incident a routine cross checking with concerned team leader was initiated in our department before sending the specimens to the lab.
Evaluation
In hindsight, the experience had both good and bad elements which have led and to an increased understanding of safe handling of specimen and my role as a scrub nurse with in the OR. My role was to prepare for the surgery, maintaining the sterility, and assist the surgeons during the time of surgery. I feel that this incident made me aware whenever I had the same situation “experience will make man perfect”. Because of this incident everybody came to know that, the errors can happen even with a patient label. On the same side the bad elements was, if the problem is not identified on the proper time, it can make unnegotiable failure in safe patient care, Entire diagnosis, prognosis, surgery out come and treatment plan will change. Patient will receive wrong results with wrong specimens.
Analysis
According to the hospital protocol we should keep a manual for safe handling of specimen, It should be reachable and readable to all the staff including the new comers. Each new staff should get a training regarding this issue when they start their career in the particular institutions. The manual should update according to the difficulties happening and make a process to follow for each type of specimen handling. It should mention the safety of the patient, health care worker and the institution. The verbal and nonverbal communication make a great part in this regard. Proper communication erases many of the problem, which are going to happen.
Conclusion
From this experience I am now more mindful of the importance being assertive and exert professionalism in practice of similar situations were to arise in the future. The insight I have gain from the experience, means that I am now more aware of the problems that can happen everywhere and any time in my working atmosphere and how they can avoid it. Strong relationship between each health care professionals should also be given a greater emphasis with in the operating room, so to increase levels of group cohesiveness.
Action Plan
In the future I am to be more proactive in dealing with a situation face on regardless of my role within the team or level of experience, this includes safe patient care, safe handling of specimen, ensuring that information is passed on to the relevant staff and intervening when I believe that is a risk to patient health and ongoing treatment. Moreover, I will address the needs of each health care workers in order to full fill their duties in a bussy schedule. If the problem may repeat, an incident report has to generate and root cause analysis (RCA) to be completed. RCA will find the source of incident and better methods can chose in future. Gradually the rate of incident will minimize and can assure a safe and healthy environment for the patient. The important points to be remembered.
- The communication between each health care worker should be clear and understandable. The mis-communication my end up with errors. Make a question in case of any doubt while communicating each other in regard of patient care.
- Interpersonal relationship and good teamwork make your work easy and perfect. Team work builds and employee cohesion and reduces medical and nurcing errors, resulting in greater patient satiffaction and improved health care. Effective team work not only improves efficiency and patient safety but leads to a healthier and happier workplace, reducing burnout among health care professionals.
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