Clinical malpractice is said to occur in a situation where a healthcare professional fails to; offer the appropriate treatment, to take the correct action, or offer a substandard treatment leading to harm, injury, or even death of a patient. Medical malpractice in most cases involves acts of negligence either in diagnosis, prescription dosage, health management, treatment, or aftercare service. Medical malpractice exposes the healthcare providers to legal action especially where a patient experiences harm as a result of the healthcare provided deviating from the expected quality of care in dealing with similar situations. To establish the legal implications of a malpractice the following factors are considered; failure to offer the right standard of care, an injury occurring out of this negligent act, and the attributed injury causes damaging consequences.
The World Medical Association noted that cases of medical malpractices were on the rise and that various National Medical Associations were seeking measures to deal with these issues. The association noted that the rise may be associated with the higher risks in the new practices, obligation placed upon physicians to tone down the medical care costs, confusion on the right health care and how to achieve it, and the role of media on engendering mistrust in physicians (World Medical Association, 2017). The World Health Organization reports that among European countries, health-care related adverse causes about 8-12% of hospitalizations. Infections arising from the healthcare were estimated to be 4.1 million patients annually. Among the Europeans, 23% of the patients indicated that they had been directly affected by a medical error with 18% claiming of this claiming to have had a serious medical error while 11% indicated that they had received wrong medication (World Health Organization, 2018). In the US, it was noted that medical errors were the third causes of death being responsible for over 251000 deaths which average to about 700 deaths daily and 9.5% of all deaths annually (Cha, 2016). In Australia, the approximate indicates that the number of deaths resulting from medical errors is about 18,000 per year while about 50000 people are said to suffer permanent injury due to medical malpractice. The Australian Commission on Safety and Quality in Health Care was established in 2011 and the formalizing of the national safety standards put in place in 2011. This paper will address clinical malpractices by analyzing an incident of a malpractice at Hope Hospital involving wrong blood transfusion to a patient and develop a remedial action place for such malpractices.
The Blood Transfusion Malpractice
The malpractice incident occurred in Hope Hospital (pseudo name) and it involved a patient, Mr. Johnson (pseudo name), who received the wrong blood type during a blood transfusion. Johnson suffered from sickle cell anemia and had sought treatment at Hope Hospital. The treatment offered exposed him to a life-threatening physical reaction and psychiatric injuries after a blood transfusion with the wrong blood type meant to treat the sickle cell disease. Johnson has had the sickle cell condition in all his life. The treatment plan for this condition sees him in need of hospital admission as well as a blood transfusion. In 2015, the patient was placed under admission at Hope Hospital after showing the sickle cell crisis. This meant that he was to receive a blood transfusion to help improve his condition. He was scheduled to receive three units of blood but midway the transfusion process, he started experiencing severe physical symptoms that caused him to have tremors, fever, vomiting, severe pain and a burning sensation. He also started falling in and out of consciousness. It was clear that something has gone wrong with the transfusion as this was not the case in other cases when he had to receive the sickle cell crisis treatment.
An investigation into this case indicated that while the patient, Johnston, had a blood type O Rhesus positive, he was given a transfusion of group B with rhesus negative. In such a condition, a natural occurring anti-B present in the individuals with Group O causes a very severe reaction to any blood group B cells. A detailed review of the cause of this indicated that the malpractice incident resulted from a human error that resulted in the wrong blood given. The biomedical scientist in charge had overridden a warning issued by the computer system when the wrong blood type was issued. The negligent act resulted in the wrong blood being issued.
Mr. Johnson’s complications became severe thereby prompting him to be transferred as an emergency case to the Intensive Care Unit of the referral hospital for comprehensive management. This involved being treated with a full automated red blood cells exchange to remove the group B cells, that were causing the reaction from his blood. This was followed by the use of intravenous steroids.
Proper management at the referral hospital saw Mr. Johnston experience gradual recovery as the physical effects of the transfusion rescinded. However, the psychiatric problems seemed to have a long effect on his ability to carry out daily routine operations. The psychological torture is exemplified by the fact that his condition of sickle cell anemia will require more blood transfusion, which makes him anxious and worried that another error would see face admitted in an ICU again.
Clinical Governance of Blood Transfusion
Clinical governance is a system through which organizations are made to be accountable for the task of ensuring continuous improvement in the nature of the patient service. It also requires the safeguarding of high standards of patient care and the creation of an environment where clinical excellence can be better achieved. In blood transfusion, the clinical governance works to ensure that all staff involved have the required training and that their performance is reviewed and audited. Certification in transfusion principles, enrolling for continuous education, and maintenance of skills are required. It is important for the clinical effectiveness of transfusion to be closely monitored to ensure appropriate transfusion practices. Hemovigilance systems focused on adverse outcomes needs to be put in place to improve quality but requires a prerequisite of data-based interventions. Application of clinical governance in blood transfusion ensure the availability of an environment where there can be open reporting and discussion of problems thereby taking formalized corrective action in a manner that ensures continuous clinical quality improvement (Benjamin, 2016).
In Australia, the National Safety and Quality Health Service (NSQHS) Standards provides the standard for blood management. The standard aims at; identifying the risks and ensure the placement of strategies to ensure that the patient’s own blood is optimized and conserved, and that any blood received for transfusion is appropriate and safe for use. The requirement is that every institution dealing with blood and blood components requires a quality management system to ensure the administering of the right amount of the right component, in the right way and to the right patient. An institution carrying out blood transfusion needs to put in place mechanisms to ensure the adherence to the national, local and written procedures. Among the issues addressed in these guidelines include the collection of blood samples for pretransfusion compatibility testing, delivering blood components to where transfusion is taking place, administration of blood and blood components, proper documentation, management and reporting of adverse events, and staff responsibilities. The health institution is at all times responsible to ensure that the process of blood transfusion is monitored and reviewed with necessary actions taken to ensure the safety of the procedures. There should be a clinical management group that reports to the Hospital’s executive and tasked with responsibility of conducting reviews on transfusion policies and procedures, review training and education programs, review adverse transfusion event, check the appropriateness of the blood transfusion and also give recommendations on the corrective action in transfusion practice (Australian Commission on Safety and Quality in Health Care: National Safety and Quality Health Services Standards, 2017).
Manifestation of the Clinical Malpractice
Indicators that a serious issue had occurred emerged midway the blood transfusion process when the patient started experiencing severe conditions such as tremors, fever, vomiting, pain and a burning sensation. These conditions could not have been experienced had the malpractice not occurred. This prompted an investigation into the case, where it was discovered that the patient was being given blood of group B Rhesus negative despite him being of blood group O Rhesus positive. The patient’s condition worsened and he had to be referred to the Intensive Care Unit for comprehensive management to remove the group B cells from the blood system through full automated red cell exchange and use of intravenous steroids.
Root Cause Analysis and the outcomes of the reports on the Blood Transfusion incident
The nurse carrying out the transfusion observed the unusual symptoms during the blood transfusion process which prompted the analyze the situation as a means of providing a remedy. A cross-check of the facts indicated that the patient had blood group O Rhesus positive. This implied that he could only receive group O blood. However, the nurses discovered that the blood that was being used for transfusion was Blood Group B Rhesus positive. The combination of blood group B and O was not compatible as it would cause agglutination of blood cells which might lead to fatal consequences. An analysis to establish the root cause of this error indicates that the biomedical practitioner had bypassed the computer system’s warning after it detected the issuance of the wrong blood type. This was an act of negligence. It was also noted that lack of adherence to clinical competency by the nurses involved in the administration of the transfusion. The nurses acted negligently by failing to cross-check the blood issued from the hospital blood bank. The hospital has policies put in place to ensure the identification of the errors before carrying out a blood transfusion were not adhered to. The patient was not closely monitored during the blood transfusion process which caused the failure of noting the reactions from the onset. A historic review indicated that there had been two other incidences that had occurred in the last two years in the hospital where the patients received an incorrect blood transfusion.
National, State, and Organizational Policies
A common principle and practice in offering health care are on clinical accountability. The principle of clinical accountability is meant to ensure improved quality of care and increase efficiency in the expenditures on the healthcare services. Enhanced accountability is bound to reduce overuse, misuse, and underutilization of the resources. Accountability also leads to the improvement of the quality of care offered by increasing the use of evidence-based medicine and performance measurement thereby reducing the cases of inappropriate care. A culture of accountability in healthcare facility leads to a decrease in the variability of healthcare quality offered.
The Australian Commission on Safety and Quality in Health Care national policies meant to guide various operations in healthcare institutions. Standard Number 7 in the National Safety and Quality Health Services (NSQHS) Standards outlines the requirements for blood management which should have guided the blood transfusion process of the patient at Hope Hospital. The standard targets for ensuring the safe, appropriate, effective and efficient blood management system.it identifies the risks in the blood management process and categorizes it into; procedural errors such as patient misidentification, errors in the sampling of blood, and transfusion of the wrong component, and reaction from the transfusion process such as fever, chills and infections (Australian Commission on Safety and Quality in Health Care, 2017). Adhering to these standards by a healthcare carrying out the blood management practices would lead to the installation of systems meant to ensure safe and high-quality practice, effective management of the available blood and blood products, safe clinical use of blood, development of strategies aimed at reducing the risks associated with transfusion.
Hope Hospital has policies in place to help prevent the occurrence of malpractices in the blood transfusion and management process. The organization has installed a computer system for the blood and blood components management. This system gives a warning whenever there is a mismatch in the patient’s blood and one selected from the system. There are policies that guide the performance of the nurses carrying out the transfusion services meant to identify any errors before the commencement of the process. The nurses are also required to closely monitor the patient during the blood transfusion process.
Breach of the Policies
The national policies on blood management were not adhered to as the blood transfusion process as evidenced by the serious reaction that the patient had. There were not attempts to reduce the risks that the policy points out to in reference to patient blood management. The national policy dealing with procedural error was not followed which resulted to a situation of a patient receiving the wrong blood type. The nurses were not attentive and failed to monitor the patient to check the occurrence of any transfusion reaction.
The biomedical practitioner failed to observe the organizational policy on the use of the warning issued by the computer system. This act of negligence and lack of accountability contributed to the issuance of the wrong blood type for transfusion to the patient. The nurses also breached the organizational policies by failing to establish whether the blood issued for transfusion was the correct one. This made them fail to identify the error done by the biomedical scientist. The nurses also failed to monitor the patient from the onset of the transfusion. Had the monitoring been done, the reactions would have been identified early enough and not midway the transfusion as it was the case in this incident.
From this incident is clear that there is some laxity on the part of the hospital’s management to carry out strict supervision on the performance of its practitioners. There is no strict adherence to the national and organizational policies by the healthcare providers. The healthcare providers at Hope Hospital seem to not be aware of the consequences of medical errors and clinical malpractices. It is clear that the healthcare providers are not offered an opportunity for continuous education as some of these issues would be greatly be discussed and thus make them more conscious of the implications for malpractice incidence. This being the third malpractice in two years, is an indicator of the absence of a committee tasked with duties of reviewing the operations involving blood management. Had some a committee existed the conditions leading to the malpractice incident involving Mr. Johnson would be have been addressed in previous recommendations and correction actions made them. The evidence is a likely indicator that the executive management at Hope Hospital are not focused to enhancing the offering of safe and efficient services to the patients which would more effective is saving on legal costs as well as wastage due to clinical errors.
Recommendations to Prevent Occurrence of the Incident
Hope Hospital should establish critical control points system in the management of patient blood. The critical control points system would provide a number of controls gateways that would ensure require authorization and approval. The computer system should not allow the bypassing of the warning issued for the mismatch in the blood and blood products issued. The system should be configured in strict reference to the national guidelines for the storage, transportation, and use of blood and blood components in healthcare facilities. The system should put in place mechanisms to ensure the continuous validations of various activities in the blood cold chain processes. Standards operating procedures should always be adhered to throughout the blood management process.
The healthcare practitioners including the nurses and the biomedical scientists should be subjected to continuous training and educational programs. This would help enhance their efficiency in the blood management operations. Such programs are effective in highlighting the various risks they are bound to encounter in the process of blood management processes, how to deal with them and the implication of negligent malpractices. The training would also offer an opportunity for these practitioners to understand any changes in the global, national, state, and organizational policies in relation to blood management. Training also helps practitioners point out the issues and difficulties that they face in their daily operations and brainstorming on the best ways to address them.
I would be important for Hope Hospital to put in place strict measures under the supervision of its staff. This would require a well-developed system of monitoring an evaluation aimed at ensuring continuous improvement along the blood management chain. This would keep the practitioners alert and prevent negligent acts that have previously been leading to malpractice incidents.
Remedial Action Plan
To deal with the reoccurrence of the issue of a patient receiving wrong blood for transfusion, Hope Hospital needs to put to use the plan described below. The plan will involve components such as computer system management, quality system, training and education, and monitoring and evaluation.
Computer system management will need to have specifications that would ensure that the policies are adhered to. An ignored warning should be shared with the supervisors and departmental heads thereby putting the biomedical scientists in check from overriding such warnings. The system should be maintained to ensure that is it is up and running through-out the day.
The quality system requires that the hospital put in place processes and procedures that can be identified, validated and documented. A key component of the quality control system is the identification of critical control points in the blood management system. This may be in terms of approvals for some critical actions. All actions should be documented with an audit trail established to point out the exact practitioner was responsible for different acts.
There will training programs for the personnel engaged in the management and transfusion of blood and blood component. These training programs will aim at helping the personnel ensure that they are fully aware and conversant with the importance of various activities in the blood management process. The nurses will be trained to sharpen their observatory skills aimed at helping them identify any reaction at the early stages of the transfusion process. There will be documentation of levels of training offered to the practitioners as well as competency assessment.
Monitoring and evaluation will be an important component of this action plan. This will aim to contribute to continuous improvements and maintain practices that are up to standard. There will be monitoring of the critical control points as well as other indicators that may affect the quality of services here. There will be regular audits and inspection with corrective measures being taken for continuous improvement.
Australian Commission on Safety and Quality in Health Care: National Safety and Quality Health Servces Standards. (2017). NSQHS Standards; Blood Management. Retrieved from https://www.safetyandquality.gov.au/wp-content/uploads/2017/11/Blood-Management.pdf
Benjamin, R. (2016). Governance and Clinical Transfusion . International Society of Blood Transfusion , 108-111.
Cha, A. E. (2016). Researchers: Medical Errors now Leading Cause of Death in United States .
World Health Organization . (2018). Data and Statistics on Patient Safety. Retrieved from http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics
World Medical Association . (2017). World Medical Association Statement on Medical Malpractice . Retrieved from https://www.wma.net/policies-post/world-medical-association-statement-on-medical-malpractice/
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