This report is a reflective essay of a critical incident analysis (CIA) which is authored by a second-year student of the Operating Department Practitioner (sODP). The paper analyses a multidimensional and multifaceted critical incident using the Gibbs Reflective cycle (1998), which focusses on communication, multidisciplinary team working and the holistic care of the patient. In this report, confidentiality is maintained as specified in the data Protection Act (1998) as well as the Health and Care Professions Council (HCPC, 2016). This literarily means that the name of the individuals, trust and location are anonymised through the report, also verbal consent was sought and approved for information disclosure.
Reflection and Reflective Practice
According to Fook (2012), reflection is the active process of reviewing, analysing and evaluating experiences, drawing upon theoretical concepts or previous learning so as to inform future improvements. Simply put, reflection is a form of mental processing with a purpose and anticipated outcome that is applied to relatively complex ideas for which there is no obvious solution.
The advantages of reflection among health care professionals cannot be over-emphasised due to the fact that it is key to improving skills and also useful for processing thoughts after critical incidents (Koshy, 2017).
Much more importantly, reflection has become a fundamental component of continuing professional development and has been identified as one of the main ways by which learning can take place from experience. Critical reflection is essential in health care, not only because it bridges the theory-practice gap, but because it optimises clinical work practices (Ghaye, 2005). The health and Care Professions council mandates registered practitioners to use reflection in their everyday practice (HCPC, 2016; NMC, 2015
The success of each reflection is based on practice and coaching in the form of a reflective cycle. There are different variety of cycles which can be used to guide the user in ongoing learning, and support, assimilation of learning and future recommendations (Howatson-Jones, 2016). Examples of the reflective cycles are Boud, Keogh and Walker (1985), Mezirow (1981), Schon reflective theory model (1993), Kolb’s experimental cycle (1984) and Gibbs reflective cycle (1998). Gibbs reflective cycle is one of the most cited reflective cycles particularly within the health sector (Rolfe, 2011).
For the purpose of this reflection, the Gibbs reflective cycle model will be used. The reflective cycle consist of six stage cycle as shown in appendix 1. The first stage is the Description where the event is described in details, followed by the assessment of the reflector’s Feelings in the second stage. The third stage is the Evaluation of the pros and cons of the experience as well as the end result of the experience, while the fourth stage focusses on the Analysis of the event the event, why things went the way it did and personal contributions to it. The fifth stage is the Conclusion which is about what could have been done differently, why it wasn’t done and lessons learnt while the sixth and last stage is the Action plan which focusses on preparation and steps for improvement and better experience for next time.
This model will be employed because it encourages a clear description of the situation at hand and also has a unique structure to follow. Also, the Gibbs model links practice and theory by challenging assumptions and exploring new ideas to promote self-improvement. However, according to Johns (2017), Gibbs reflective cycle lacks an intellectual edge over other approaches, however the last stage of Gibbs allows for a new cycle of reflection.
The SODP reflected using the Gibbs reflective cycle as it was found to be straightforward and well-structured. .
Critical incident analysis (CIA) is an approach to dealing with challenges in every day practice particularly in medical and other sensitive areas (Lister, 2007). The process of the CIA is to comprehensively investigate the details of an incident which will include likely causes, persons involved, when, why and how it happened and a recommendation for future practice/occurrence.
According to Jasper (2011), CIA is the examination of such incidents which allows for detailed scrutinisation, the root cause of the incident and how to affect change to future practice. It is termed ‘critical’ because it is significant, while it is an incident because it is an instance of something happening. CIA is based on real-life situations which promotes active engagement of professionals in the construction of their own knowledge (Okes, 2009). CIA is often employed to assist reflective learning in practice (Lister, 2007), although it can also expose the vulnerabilities of the learner as well as increase in anxiety levels. (Vachon, 2011). However, Lister (2007) believes that CIA is a valuable tool, which enable practitioners to develop an anti-oppressive practice.
The analysis and evaluation of CIA are done using specific tools, referred to as Root Cause Analysis (RCA) tools (Okes, 2009). These tools allows for a systematic investigation to ascertain the reasons behind the incidents in order to prevent further reoccurrence (Anderson, 2006). In addition, RCA are useful in detecting areas for change, improvement and recommendations particularly in the health care settings which ultimately allows for safe and effective patient care.
There are different investigative tools for conducting RCA such as Ishikawa Fishbone diagrams, brainstorming, flowcharting, the Five Whys and the Affinity diagrams (Andersen, 2010). The Five Whys is one of the simplest RCA tool, because the investigator keeps asking ‘Why’ until a meaningful conclusion is reached. The Ishikawa Fishbone diagrams are mostly useful when the ‘Five Whys’ is too basic to be used, it is a causal process which seeks to understand the possible cause by grouping it into subcategories (Barsalou, 2015). The author has chosen to use the 5 Whys technique (Shown in Appendix 2) due to the fact that it is simple, effective and also more appropriate for the CI discussed.
Gibb’s reflective cycle – Six stages
Description – Appendix 1
A complete description of the incident involving the misidentification of a patient is detailed in Appendix 1.
Prior to the incident, the student was in a good mood, having only just entered the hospital and changed in to the right uniform. After it was discovered that surgery was almost performed on a wrong patient (near miss), the student felt devastated that such a mistake was made, an error which could have been potentially fatal and catastrophic if it had gone unnoticed. The student was dejected, sad and scared and had a quick think about her practice and her future in such a profession where such an error would have caused disastrous consequences which could led to resignation and end of careers. One good feeling the student had was that the Health Care Assistant’s (HCA) support in admitting that she made a mistake while printing the identification tags.
There were both negative and positive aspect about the incident. The main negative aspect was misidentification of the patient which could have resulted in a disaster if the error was not picked up. As a risk management tool, the WHO sign out section verified that all specimen description, quantity and patient identification are correct (WHO, 2009). A negative feature was the HCA’s incorrect printing of the identification tags at the patient ward. It is imperative that once an identification tag is printed, it is accurately checked with the patient before it is used as a wrist band tag for the patient or as a label for the patient’s items.
On the positive side, the mistake was spotted, therefore preventing a never event. The HCA also acknowledged that printing the wrong stickers and labels and not double-checking with the patient is bad practice. However, the error was corrected when the HCA ask the patient itself before entering the theatre and the patient confirmed the name and other details were wrong. This prevented a ‘never events’, which according to the department of Health, (DoH, 2012) are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all health care providers.
Acknowledging her limitations, the student did not complete the specimen book hence waited for the HCA. Although the specimen responsibility lies with all parties, it is worth mentioning that professional accountability lies with the surgeon and the scrub practitioner (Local Trust Policy, 2017).
The department of Health (2010) states that Health organisation and professions have a duty to provide quality and safe care and this should be expected by the community they serve. The introduction of the 6Cs are the value base for leading change and they were one of the great legacies created through ‘Compassion in Practice’, a three-year strategy that was concluded in March 2016. The 6Cs are care, compassion, competence, communication, courage and commitment.
These 6Cs are embedded into everything and are set of values to compassionate care which allows practitioners to work in an effective, efficient and safe manner (Department of Health, 2012). It ensures that patients are safe and practitioners use a holistic approach towards patient care.
The UK National Health Service (NHS) introduced Clinical Governance in the 1990s to tackle over spending which has become an ineffective management system causing an overall low public confidence in the NHS. This frame work ensures that all individuals and providers can assure the provision of good quality care which can be improved upon continuously (Department of Health, 2011). Clinical Governance ensures the safety of patient and risk management (Flying Start, NHS 2016). In the same vein, national organisations were established such as the National Institute for Health and Care Excellence (NICE) and the Care Quality Commission (CQC) were created to establish and maintain high standards of patient safety and quality (Haxby, 2010).
Clinical Governance is made up of seven pillars known as education and training, audit, clinical effectiveness, patient and public experience, risk management, information & IT and staff management (Haxby, 2010). The local trust has adapted six themes from the seven pillars which are information focus, staff focus, patient focus, quality improvement, leadership and Public Health. The provision of a full and comprehensive patient care can be realistically achieved when all the clinical governance pillars/theme are met.
The application of the Clinical Governance with the Five Whys showed that incident described in Appendix 1 was multifactorial which means caused by a number of issues. Key factors involved in the incident which will be analysed, includes poor communication, team work, staff focus, wrist band tags, WHO checklist, breach of information, breach of clinical effectiveness, inadequate teamwork and risk management.
Poor communication is bound to cause problems particularly within the health care sector. Working as a team and effective communication are requirements by the HCPC (Leonard, 2004) in order to uphold the standards of clinical governance which all health care professionals should follow (DoH, 1997). In this incident, communication, team working and following protocol is very good which was why the mistake was discovered. According to Vermeir (2015), communication is integral to all the seven pillars of clinical governance, Deland (2018) showed in the article that there are strong positive relationship between a healthcare team member’s communication skills and a patients’ capacity to follow through with medical recommendations, self-manage a chronic condition and adopt preventive health behaviours.
Good team working has also been reported in numerous papers to have a significant effect on the improvement of patient outcomes and the enhancement of patient safety in a dynamic and approach which will reduce human factors that can leads to patient safety incidents. According to Carayon (2013), human factor is bound to cause natural human error which may significantly impact upon patient safety. However, this may be minimised by employing good team work approach and effective communication in all patient related cases. According to the World Health Organisation (WHO, 2008) communication failures are the major cause of many health care related incidents or near misses. In this particular case of misidentified patient, poor communication could have escalated the incident if the HCA failed to inform other team members of the error. More importantly, the highest hierarchy among the professionals in the surgical ward took the position of an assertive leader and made decisions on who, how and what to report as incident. The CQC (Care and Quality Commissions) requires reporting of ‘incidents’, ‘near misses’, and ‘never events’ which may incur penalties for the organisation. Reporting incidents including ‘near misses’ is an aspect of risk management which allows providers of health care services to learn from mistakes and develop subsequently strategies to improve patient safety. Incident reporting is not to blame anyone but to avoid the recurrence of such incidents which could be catastrophic and damaging.
According to the 2016 National Patient Misidentification Report, there are clear and profound data on the causes and impacts of patient misidentification problems in health care. The report covers responses from more than 500 participants who are responsible for clinical delivery and financial operations. Some of the findings from the report showed that 84% of survey respondents agree that misidentifying a patient can lead to medical errors or adverse effects. Also, the primary root cause of patient misidentification is incorrect identification of patients at registration according to 63% of respondents. Furthermore, the report stated that a patient is misidentified in a ‘typical’ health care facility very frequently or all the time. This is due to errors such as inability to find a patient’s chart or medical record (68% respondents), a search or query resulting in multiple or duplicate medical records for the patient (67% respondents). Others are the pulling of wrong record for a patient because another record in the registration system or EMR has the same name and/or date of birth (61 percent respondents). Finally the report states that an average hospital loses approximately ?15 million per year in denied claims resulting from patient misidentification.
According to Khomeiran (2006), professional competence is as a result of practice efficiency coupled with combination of experience and theoretical knowledge. The student felt personally responsible for the event because of failure to check the patient and deemed it fit and ok to undergo the surgery. Also, the student should have checked the patient with the structures document in the online record sheet to be double sure of the correct identification. On the bright side, the student was working within the limitations of my scope practice, and effective learning and teaching as a team is part of the training aspects of clinical governance.
Conclusion to the cycle:
The Gibbs reflective cycle has been used to analyse and rationalise the critical incident that happened in the theatre as a result of misidentification of a patient. As identified by the RCA, the features of the critical incident included communication, wrist band tags, first point of registration, incident reporting and accurate identification checks. It is worthwhile to state that communication was very good and it helped to achieve a positive outcome for the patients. Also, the health care providers followed due process to report the incident, which will allow others to learn from the error. Personally, I am now aware of the important of being more assertive and followed protocol to the last word if similar situations were to arise in future. Although I believed I could have saved the situation and spot the error on time, however the experience I have gained from this have increased my awareness in acting in the best interests of patients even if this means double-checking a fact. This may be the conclusion of a single learning experience from a critical incident, however it is the beginning of my development as a professional in my chosen career. This experience would go a long way in shaping my skills, talents and abilities in the long course of my career in the operating theatres.
In future, if similar incident occurred again, I know what to do, which is to carefully check the patients with the medical records and look for distinct signs that identifies the patient about to undergo surgery. Also, my future practice will involve being more proactive particularly when I strongly believe there is risk to patient safety. I will not assume that other professional staff would have acted in a professional manner and spot all the mistakes. In addition, I will continue to employ the use of Gibbs reflective model (1998) to reflective on my day to day to activities. This will help me to effectively apply my clinical skills in the maintenance of patient safety and the implementations of the values and principles set by the HCPC.
Positive patient identification is the foundation of effective healthcare because it allow the right care to be delivered to each patient based on his or her individual needs. When a patients comes through the door of the surgery room, if the correct medical chart with correct patient information is not accessed, there can be serious repercussions. This could result to loss of money in court settlements and also the damage of reputation of the medical personnel and rust involved. This incident has taught me to realise that proper patient ID confirmation at every step of clinical care is essential to patient safety. On reflection, I have ascertained that patient identification errors can be avoided by improving usability of physical, electronic and assigned patient identifiers by using well-designed ID alerts during order entry. Also, healthcare facilities can design and implement an effective patient identification system that identifies patients accurately and retrieves their correct medical record.