Patient Safety: We could be the killer!

Mayjor Wong, BSN, RN

It took me a while to come back to writing after a nap that rested my mind that exhausted for the entire busy and hectic week that I have had. I have been thinking for the entire night about thing I have learned after the event that encountered yesterday in relation to the issue of 'Patient Safety'.

I had a trembling and shocking day yesterday where I witnessed myself how my colleague delivered a shock to my client with a stable rhythm unintentionally when performing the device system check. This result my client's heart rhythm deteriorated to a life threatening rhythm 'Ventricular Tachycardiac', although it was still in a perfusing rhythm at that time but his hemodynamic compromised significantly. I would say 'defibrillator' supposes is considering a life saving device. Somehow it could be a device that can jeopardize and lead to fatal if we use it inappropriately. Luckily, we are able to revive and salvage our client after the electrical and chemical cardioversion.

Well, as I said the medical equipment can be a life saving device and it could be a device that leads to lethal. This is evidence in the available data that reported the incidence of 0-6% IABP rupture and cause helium gas or air emboli. In other hand, data also demonstrated that the incidence of pulmonary ischemia, infarct and rupture due to inappropriate placement of Pulmonary Artery Catheter is significantly low where account for 0.2% of probability, however, it is associated with high mortality rate up to 50% if it happened. I would say, sometime the 'tragedy' can be avoided if we uphold the significant knowledge, understanding and skill how to handle the equipment in the right manner. Somehow, most of the time, lots of people still neglected the crucial facts and information which might lead to life of others being jeopardize.

However, my prediction telling me that it changed the entire plan and management for the client significantly because of this event. This was because our primary ICU team physician thought that the client is not doing well with the weaning and condition turned back.

According to the initial strategy and management that planned in 24 hours ahead and during morning ICU round immediately prior the event, the client suppose will proceed with the ECMO explantation in Cardiac OT which arranged by CTVS registrar on call and primary consultant. However, because of the VT event, the plan for explant was change instantly and decided to perform ICU instead as the entire team thought that the client was not stable enough transport to OT. Somehow, the plan for explantation is abandoned as claimed to have family issue of concerned. Well, this could be my assumption, may be there is other reason behind to change their plan that lead them to decide explant in ICU.

During and after the event, I did approach the colleague that involved and talk to her about her action that lead to patient's rhythm being compromised. I understand how she feels, her feeling of fear at that moment and I could forgive her action that lead to patient's life being jeopardize and perhaps can be fatal because I knew that was unintentionally and subconsciously. Somehow, I feel very disappointed and I don't think I can forgive her where she attempted to destroy the evidence of rhythm strip that printed from the defibrillator while I was rushed to get Amiodarone from our unit Omicel medication system.

My dear colleague, frankly speaking I do not have the intention to test your honesty and integrity? But don't try to make fool of me as you still haven't reach that stage. Although you have destroyed the evidence, somehow I still can retrieve back the evidence if I wanted to. Although the defibrillator do not have the data storage card, however, it is equipped with the internal event summary that can store up to 300 events and up to 50 6 seconds strip.

Again, It is not my intention to lower your self-esteem and demoralized you from this event. I know if I forward this issue to the higher authority and management level and you will in the great trouble. Somehow I sincerely hope that you can perform your self reflection and have the self-conscious to learn from this incidence, take this incidence as your learning point and do not repeat it again.

Life is full of choices and you can choose not to learn from this incidence. It is your personal choice, somehow, I sincerely hope that you will learn from it and be more vigilant at work and try not to put your client in life danger. Most importantly uphold the 'safe practice' as simple as that.

Patient Safety: We could be the killer!

About Mayjor Wong, BSN, RN

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