Being a leader in my field means I am often contacted by colleagues for advice, or support. Last week I had one such call from a senior VN who was understandably upset because a patient had died under anaesthesia while in her care. The case was a tragic convergence of events, the wrong things happening at the wrong time, and resolving any one of those events could have changed this outcome from death to a survival.
The case began with the senior VN going to lunch and thinking that the planned orthopaedic surgery would be started after her return. As soon as she left, the new vet decided to start the surgery immediately, but didn't realise the implications of having only two junior VNs working at the time. Once the patient was anaesthetised, a medication was given into the drip line under the veterinarian's instruction, and the patient started to have an anaphylactic reaction to the medication, but the signs weren't obvious until it was too late. The patient's temperature began to drop, but the junior VNs didn't notice it because they weren't taking the temperature more than once every 30 minutes. The patient's respirations decreased, but they didn't notice because the ap-alert monitor continued to make reassuring beeping noises every so often. The patient's oxygen saturation began to drop, but only by a couple of points and the type of monitoring sheet they were using didn't allow them to see the trends very easily. You can see where I'm going with this…I don't need to tell you about the assisted ventilation, faulty blood pressure probe, or insufficiently cuffed endotracheal tube. Suffice it to say, when the senior VN arrived back to work and found the patient near death, immediate resuscitation began, but it was too late.
To be clear, this is a good clinic, with well qualified staff and sound policies in place. There were a number of problems that contributed to this patient's death. One of the key issues was a dependence on machines rather than observational skills. Machines should only be used as a supplement to assist good nursing care. Anaesthetic monitoring requires diligent, frequent, and careful evidence-based observations. Data must always be recorded, and in such a way that trends can quickly and easily be seen. Any deviations from normal must immediately be reported to the responsible person (usually the veterinarian carrying out the procedure). Good communication is essential in the veterinary practice. It transpired that these junior VNs were afraid to bring up problems with the veterinarian — this is a problem that all of the staff need to work on, especially the veterinarians who need to be approachable for reasons like this. In addition, the question remains whether the junior VNs should have been alone with no senior VN to monitor their actions. What does a junior VN say when asked by a veterinarian to assist? Are the rules clear to make sure that all staff know the limits of their responsibility so that they can say ‘no’ when asked to do things beyond their level of expertise? And what about the senior VN? Should she have been more active in communicating with the new veterinarian to be sure that they were aware that the surgery would happen as planned when she came back from lunch?
Finding fault in situations like this is complicated. It's possible that the patient could have been having a fatal reaction to the medication and death may have occurred anyway. However, examining the reasons for the issue is important in order to learn from the experience.
The sad thing about this is the unnecessary loss of a patient, but it is a useful reminder to us all to take care at each and every step. To constantly re-evaluate our practices and to always use our own observational skills instead of relying on shortcuts.
We hope you enjoy this issue.