Post-operative haemorrhage reporting
Part 1
Postoperative haemorrhage is the bleeding observed after a procedure involving a surgical operation (Bonjer and Cuesta 224). The bleeding may be delayed, or it may happen immediately after the procedure.
The prevalence of postoperative haemorrhage
In 2000, the prevalence of postoperative haemorrhage in the United States was estimated to be as follows:
An occurrence of 2.24 postoperative haemorrhages with evacuation or surgical drainage per 1000 surgical discharges, 1.02 postoperative haemorrhages of people with the age range of 0 to 17 per 1000 surgical discharges and 1.5 postoperative haemorrhages among people of ages 18 to 44 per 1000 surgical discharges.
A scenario involving post-operative haemorrhage
A 40year old woman who had a myocardial infarction history and was fully beta-blocked went for a hemi-hepatectomy so that metastases could be removed from a colon cancer that she prior had from the right lobe of her liver. The patient got in the ICU experiencing slow pulse (70/min) and a less serious hypertension (140/90) that was attributed to pain. The preliminary haematocrit was about 32%. In the next seven hours, there was a decline in blood pressure to about 105/60 of which the trainee attributed to adequate pain control. Urine output went to 20 ml/hour but was not recognised. Pulse was slow, less than 80/min. When another haematocrit was again checked, it was 19% with marked prolonged coagulation parameters. The patient was then immediately taken back to the theatre where one litre of blood was transfused, and a small artery was tied up.
Who was involved in the event and their roles
The key player in this event that led to postoperative haemorrhage was the trainee. The kind of the problem was enough to suggest that the involved trainee had difficulty in identifying risky post- operative bleeding (Bonjer and Cuesta 224). For this trainee, the likely challenge was that he never had enough experience since he had spent a little time during his training in post-operative surgical ICU, and might have only dealt with patients suffering from post-operative bleeding after their arrival in the operation room. Another problem that might have led to the tragedy was self-governance and inadequate communication between the trainee and his colleagues.
Stakeholders among the CQI team and their differences that might cause issues when working as a team
The stakeholders in CQI are mandated to ensuring that there is a continuous improvement in a system in an attempt to prevent any future problem from occurring. These stakeholders include: persons and families served, employees, volunteers and consultants, consumer advocates and all level of agency staff. During the role execution by the CQI team, some differences may arise like interaction problems, confused goals, personality conflicts among the stakeholders and even the perception of being self-reliant and independent thereby not being free to seek for any assistance from other stakeholders. Some of the barriers to effective communication among these stakeholders that compromise proper cooperation are cultural barriers, language barrier, an emotional barrier that arises from mistrust and even perceptual barrier due to the difference in opinions. Some of the communication methods utilised to inform the organisation’s staff of the adverse event improvement plan include handwritten notes, text messages and emails.
Operational or safety processes that might not have been followed during the event
The case of post-operative haemorrhage might have been attributed to ignorance of the trainee to observe recommended safety processes. Among the safety processes that might have been overlooked by the trainee include a sound clinical judgment and adequate assessment and preparation of the patient. To prevent the occurrence of this event, he would assess the patient’s pulse rate, blood pressure, haematocrit level, and the urine output. The regulations that the accrediting agencies would utilise to measure the compliance with the standard so as to prevent the occurrence of a similar event is by ensuring that there is a perfect integration of surgical expertise, anaesthesiologist and a fully equipped interventional radiology.
Contemporary issues and legal implications related to patient safety in surgical environment
Steps taken in ensuring a patient’s safety in the surgical operation room start before the patient enters the suite and includes attention given to preventing medical errors from occurring. Some of the contemporary issues that have to be considered include the process of the procedure verification whereby the team has to ensure that the relevant documents and related equipment are available, correctly identified and labelled. Any discrepancies or missing information has to be addressed before the procedure begins. There is a need of a stepwise and methodical surgical approach so as to selectively dissect and also in the identification of the bleeding site. There is also a need for performing a “time out” before the procedure. It is a serious breach if the patient is not monitored and treated postoperatively for any possible infection. Apart from the possibility of infection, post-operative care should include measures that prevent blood clots. The patient should be involved in the event to avoid errors during the operation. This involvement requires surgeon’s education to the patient during the process of preoperative evaluation.
How processes of continuous quality monitoring impact on the postoperative haemorrhage
Continuous quality monitoring plays a vital role in the prevention of postoperative bleeding. A report shows that those patients who had deteriorating conditions were not monitored and referred for a proper level of care. The engagement of physicians, nurses, quality improvement department representatives and surgical technicians in preoperative and intra-operative stages ensures proper management of blood loss, and also in the determination of anticoagulant medication before the procedure thereby guarantees the prevention of post-operative haemorrhage. Continuous pre-operative monitoring and appropriate measures involving taking patient’s disease history, medication and paying special attention to the possibility of a pre-existing coagulation disorder are crucial during the monitoring process in preventing any possible post-operative haemorrhage.
Part 2
The hospital has recorded cases of post-operative hemorrhage in the last two years as shown in the table below.
As shown in the above table and graphs, there was an increase in the frequency of postoperative hemorrhage in 2015 from the number reported in 2014. This shows a reduction in the efficiency of the procedures established to prevent such cases. It may have been due to inadequate skills, failure to adjust to changing operating conditions, among other causes.
Fishbone diagram
The above problem can be expressed in a fishbone diagram. It identifies and classifies the causes of post-operative hemorrhage as shown below (Dahlgaard, Kristensen and Kanji)
Part 3
I would recommend additional and continuous training of the staff to enable them to understand modern operation procedures. Any operation should have at least five specialists to avoid human error. Besides, the management should invest in technological improvement and acquire modern equipment. There should be a well-written guideline on conducting certain procedures. This should be communicated to all the staff concerned.
Works cited
Bonjer, H. J and Miguel A Cuesta. Case Studies Of Postoperative Complications After
Digestive Surgery. 3rd ed. Springer Science & Business Media, 2014. Print.
Dahlgaard, J. J, Kai Kristensen, and G. K Kanji. Fundamentals Of Total Quality
Management. 3rd ed. London: Chapman & Hall, 2008. Print.
