Addressing risks in the environment of a hospital or a similar facility is an indispensable element of healthcare. Until all the factors that jeopardize patient well-being are identified, quality of service will remain low, and the rates of recovery are likely to drop. One might argue that predicting all scenarios in which the patient may be affected negatively is impossible. A case in point – the instance of a patient contracting a nosocomial infection after surgery – should be viewed as a graphic representation of inadequate delivery of services. The case in question points to the need to focus on compliance with the established regulations as far as the process of surgery is concerned.
George M. is a 57-year-old Caucasian man who suffers from a multiple myeloma condition. In order to administer the necessary treatment to the patient, the use of a central line, i.e., a central venous catheter, as the means of managing the patient’s condition was suggested. The patient was undergoing chemotherapy in a local facility. A central line was implanted to administer the necessary medications (Cyclophosphamide (Cytoxan)) to the patient. A Broviac catheter was embedded in the course of the surgery. However, because of the lack of proper sanitation in the environment of the operation room, as well as the negligence of staff members, the damage of a blood vessel must have occurred. As a result, the patient contracted a CLABSI, which manifested itself in mild fever during the first several hours after the surgery. After the fever had been followed by swelling and an increase in the patient’s heart rate, George M. was diagnosed with a CLABSI. To be more accurate, the patient contracted Staphylococcus aureus as a result of the surgeon’s and the healthcare assistants’ negligence.
How the Event Was Detected: In Retrospect
The problem was identified shortly after the catheter was implanted due to the unceasing fever and the associated symptoms (i.e., fast heart rate, swelling, etc.). To be more accurate, the incident was detected as the changes in the patient’s heart rate, and the temperature was identified with the help of the hospital equipment (Krein et al. 2015). The incident report can be considered as an essential tool that led to locating the problem and developing a set of measures for addressing it. Particularly, the possibility of the patient developing a CLABSI was suggested after reviewing the information from the report.
Although the identified tool cannot be viewed as the most trustworthy device for acquiring essential information, it does shed light on incidents that do not seem to align with expected patient outcomes (Anderson et al. 2013). Furthermore, the use of the report allows staff to identify the exact point at which the problem started, as well as identifying the factors that may have contributed to the development of the problem. As a case in point, the scenario described above shows that the patient started developing mild fever shortly after the surgery. As it is the case that surgical interventions may cause minor inflammations, the specified phenomenon was not given proper attention, which clearly was a mistake.
One might argue that the lack of concern for the inflammatory response could be justified by the fact that such a reaction typically follows surgery in a range of instances (Visser et al. 2015). However, studies show that the identified scenario requires an immediate analysis of the factors that may have contributed to the inflammation and the ensuing identification of the treatment steps (Loubon et al. 2015). The lack of concern for the information represented in the report, therefore, points directly to the fact that the management of CLABSI and the related issues should start with the redesign of the ethical and quality standards in the environment of the identified healthcare facility.
It should be noted that the lack of emotional intelligence among healthcare experts inhibited the identification of the problem to a considerable extent. Although the patient could not talk, the changes in his facial expression pointed directly to a problem. Therefore, when considering possible risk management strategies, one should consider increasing the staff’s competencies first.
Much to the credit of the members of the facility, the process of disclosure was carried out in a timely and honest manner. The information about the CLABSI issue and the possible means of addressing it was provided to the patient in accordance with the existing standards. The apology, while being rather short and unemotional, was also delivered to the patient. It is suggested, though, that the process of disclosing the essential data to the patient should be followed by more active support. Although the crucial information was explained to the patient, the options for the further treatment of the CLABSI issue were not outlined fully.
Another problem, which the approach used by the healthcare members incorporated, concerned addressing the issue caused by their negligence. Although the victim of the healthcare error was provided with a brief description of the prospects that he had, the hospital members offered a rather scanty range of options for full and free management of the issue. The quality of the free services that the personnel, including the surgeon, listed as the possible means of managing the CLABSI issue, included cheap antibiotics yet did not provide the medicine for antifungal therapy. Though the development of fungi will not necessarily appear as a result of the active use of antibiotics, there was a possibility that the patient could have developed the identified problem.
Granted that the course of actions taken by the healthcare staff was quite understandable in light of the direct medical costs that the facility would have suffered, but there was no justification for the low quality of the services suggested to the patient as the means of managing the issue. Therefore, the disclosure process did not follow the existing standards completely. The lack of care for the well-being of the patient, combined with the absence of empathy, created a rather hostile environment, in which the patient’s chances for a recovery dropped significantly. Close scrutiny of the way in which the CLABSI issue was addressed in the case showed that the facility needed a patient-centered approach as the means of addressing the threat of nosocomial infections and that the risk management framework that the organization utilized needed to be shaped. Particularly, the introduction of a patient-centered strategy would help alter the current risk management framework toward a more careful identification of the threats of nosocomial infections, as well as a better management thereof (Ross 2013).
To analyze the nature of the problem and determine the faults in the current risk management strategy that have led to the incident, the Risk Manager applied the Root Cause Analysis (RCA) tool. One must admit, though, that the process of detecting factors that may have affected the situation was rather difficult since a considerable range of factors that could have caused the CLABSI development had to be reviewed.
The RCA analysis showed that the prolonged hospitalization prior to the insertion of the catheter must have played the greatest role in infecting the patient. Combined with the intrinsic factors, such as the patient’s age and gender (57, male), the long stay in the hospital environment must have played a drastic role in the change of the patient’s health status.
At this point, one must mention that the current risk management framework used in the target facility cannot be deemed as appropriate. Although identifying every factor that may inhibit a successful surgery and the process of recovery is barely possible, essential principles for maintaining high safety rates must be followed, which was not the case in the identified scenario. The patient was clearly supposed to undergo surgery much earlier than he eventually did; as a result, the CLABSI development became practically unavoidable. Therefore, the current risk management strategy needs to be redesigned, so that patient outcomes become more positive (Yokoe et al. 2014).
When considering the tools that are likely to serve as preventive measures in managing the CLABSI issue, one should consider changes in the current leadership and ethical frameworks. As detailed in the case, the changes in the patient’s well-being were easily recognizable shortly after the surgery, yet little to no attention was paid to the problem. Therefore, it is necessary to promote a more patient-centered approach among therapists so that every change can be reviewed on a case-by-case basis. Thus, the individual responses of the patients toward treatment and surgery can be interpreted properly, and the emerging issues can be addressed adequately.
Furthermore, staff members must be provided with opportunities to increase their competencies and acquire new skills. As stressed above, the discomfort that the patient experienced could be identified at a comparatively early stage of the problem development. If enough attention was paid to the emotional connection between the patient and the healthcare experts, the issue could have been addressed much earlier. Therefore, there is a necessity to introduce new training opportunities for the staff.
When designing risk management (RM) strategy that will help prevent the instances of CLABSI in the future, as well as preventing other problems from occurring in the context of the specified healthcare facility, one must ascertain that the essential elements of the risk management framework have been included in the RM strategy. Particularly, the following items must be considered as the foundation of an efficient approach: risk identification, risk assessment, and risk treatment. In the target environment, the risk management processes must be launched once the patient is admitted to the facility. The procedure will include such stages as the identification of internal (i.e., patient-related, such as age, gender, etc.) and external (i.e., pertaining to the hospital environment) threats that may contribute to the development of CLABSI and similar issues after surgery (Agency for Healthcare Research and Quality 2016).
Resolution With the Patient
The patient declined to file a lawsuit against the hospital. However, he demanded better services with an improved focus on his personal needs. As a result, a settlement was arranged.
As far as the operation room risk management is concerned, the devices for patient monitoring must be maintained in perfect working condition. Furthermore, the instances of anesthesia malpractice must be prevented successfully. Studies show that the lack of proper care during the provision of anesthesia to the patient may result in the latter receiving a severe injury (Kozek-Langenecker et al. 2013). In order to make sure that anesthesia-related risks are prevented, one must follow the pre-use checklist, including the use of any necessary supporting equipment and medicine so listed.
The importance of physiologic and multiple medical gas monitors can hardly be overrated, either. It is crucial to maintain patient safety at the highest level possible and detect any changes in the patient’s well-being at the earliest stages of development. Therefore, it is crucial that the upgrade in the technology used in the course of surgery should be considered as an essential step in improving the current risk management system.
It should be borne in mind, though, that the changes listed above must be carried out in the context of an improved workplace environment. Put differently, the ethical principles and the quality standards by which the employees must be guided in the process of decision-making have to be revisited so that the risks could be addressed properly. Along with the change toward a patient-centered approach, the managers of the healthcare facility in question must consider the promotion of a more responsible attitude among the staff members. The principles of Corporate Social Responsibility (CSR) must be viewed as the foundation for further prevention of CLABSI-related outcomes in patients and more efficient management of the risks associated with the provision of the necessary healthcare services.
Agency for Healthcare Research and Quality 2016, Tools for reducing central line-associated blood stream infections, Web.
Anderson, JE, Kodate, N, Walters, R, & Dodds, A 2013). ‘Can incident reporting improve safety? Healthcare practitioners’ views of the effectiveness of incident reporting’, International Journal for Quality in Health Care, vol. 1, no. 1, pp. 1–10. Web.
Kozek-Langenecker, SA, Afshari, A, Albaladejo, P, Santullano, CAA, Robertis, ED, Filipescu, DC, & Wyffels, P 2013, ‘Management of severe perioperative bleeding. Guidelines from the European Society of Anaesthesiology’, European Journal of Anaesthesiology (EJA), vol. 30, pp. 267-382. Web.
Krein, SL, Kuhn, L, Ratz, D, & Choppa, V 2015 ’Use of designated nurse PICC teams and CLABSI Prevention practices among U.S. hospitals: A survey-based study’, Journal of Patient Safety, vol. 9, no. 3, pp. 122-128. Web.
Loubon, CO, Hinojal, YC, Carreras, EF, Nuñez, GL, Peláez, PP, Sáez, MB, & Molina, MF 2015 ‘Extracorporeal circulation in cardiac surgery inflammatory response, controversies and future directions’, International Archives of Medicine, vol. 8, no. 19, pp. 1-13. Web.
Ross, TK 2013, Health care quality management: Tools and applications, John Wiley & Sons, New York, NY.
Visser, M, Niessen, HWM, Kok, WEM, Cocchieri, R, Wisselink, W, van Leeuwen, PAM, & de Mol, BAJM 2015, ‘Nutrition before and during surgery and the inflammatory response of the heart: A randomized controlled trial’, Journal of Nutrition and Metabolism, vol. 2015, no. 123158, pp. 1-8. Web.
Yokoe, D S, Anderson, DJ, Berenholtz, SM, Calfee, DP, Dubberke, ER, Ellingson, KD, & Maragakis, LL 2014, ‘A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates’, Infection Control & Hospital Epidemiology, vol. 35, no. 8, pp. 967–977. Web.
Central Line-Associated Blood Stream Infections