Safety Issue that was Ignored
There were safety issues that were apparently ignored in the Elaine Bromiley case . The issues allegedly stem from the inability of health care professionals to adhere to the Difficult Air Society (DAS) guidelines (Difficult Air Society, 2013) especially when the patient exhibited “can’t intubate, can’t ventilate” situation . As such, one of the safety issues that was obviously ignored in the case is the lack of cognizant observance of the crucial essence of time that the patient has been in recognized to experience lack of oxygen. In fact, a review asserted that “the clinicians appeared to become oblivious to the passing of time and they lost opportunities to limit the extent of damage caused by the prolonged period of hypoxia” . Therefore, not having followed the DAS guidelines resulted in failure to provide appropriate air passage to the patient and resulted to extensive brain damage and eventual decision to remove life support system thirteen days after supposed routine sinus surgery.
How the Outcome could have been Altered
Safety Measures which could have Helped to Protect the Patient
Review of the case and several literatures indicated that the DAS guidelines were fairly new when the incident happened . As such, several recommendations were proposed to improve safety and prevent similar situations in the future. These safety measures include the following: (1) ensure that healthcare practitioners are all familiar with the DAS guidelines and the copy of updated guidelines should clearly be visible and displayed in anesthetic room; (2) one of the staff nurses should have the responsibility of clearly communicating through verbal means the time transpired in emergency situations, especially with regard to oxygenation of patients; (3) proper endorsement and accountability of leadership or governance for the patient should be established; (4) transfer of care should be structured, documented and formalized (meaning the anesthesiologist should have properly monitored the recovery of the patient and should have not accepted other responsibilities while the patient has not fully recovered); (5) proper and continued monitoring of vital signs should have ensued while in the recovery room and immediate endorsement for transfer to the intensive care unit should have been proposed earlier for immediate application of recommended medical intervention, as deemed needed. All of these errors were definitely considered human factors and their identification of weaknesses and loopholes in the delivery of patient care should be urgently addressed.
References
Difficult Air Society . (2013). DAS Guidelines. Retrieved from das.uk.com: https://www.das.uk.com/guidelines
Harmer, M. (2005). Independent Review on the care given to Mrs Elaine Bromiley on 29 March 2005. Retrieved from chfg.org: www.chfg.org//Anonymous_Report_Verdict_and_Corrected_Timeline
Laerdal Medical. (2011, July 6). Just A Routine Operation. Retrieved from YouTube: https://www.youtube.com/watch?v=JzlvgtPIof4
Royal College of Obstetricians and Gynaecologists. (2013). Human factors case study: Elaine Bromiley. Retrieved from rcog.org.uk: https://stratog.rcog.org.uk/tutorial/human-factors/human-factors-case-study-elaine-bromiley-8887
Update in Anesthesia. (2004). Failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed anaesthetised patient. Rescue techniques for the “can’t intubate, can’t ventilate” situation. Retrieved from medicalistes.org: sofia.medicalistes.org/spip/IMG/pdf/Can_t-intubate-can_t-ventilate.pdf
