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31 Mar 2019 1015 Views Sarah


The surgical procedures and patient safety issues are always associated. Assuring patient safety in the surgical room or the operating room starts prior the patient is entered into the operation suite. The safety issues can compromise the perioperative outcomes. It is doubtless that patient safety is the universal requisite. The prevention of surgical errors is the responsibility of all the surgical team members. But, the nurses play the powerful role in providing safe care to patient undergoing surgery due to their extremely close relationship with patient. This essay is portraying three phases of surgical journey including preoperative, intraoperative and post-operative care of 65years old Australian woman. She is Mrs. M (pseudonym) who underwent a modified radical mastectomy of her left breast. This essay is focused primarily on presenting the ethical and legal considerations to be followed during the entire surgical process for enhanced patient safety, improved surgical team work and effective communication.

This analytical essay begins with the provision of Mrs. M’s brief history representing the symptoms and indications for her mastectomy. Mrs. M was diagnosed with stage 2 adeno carcinoma (malignant tumour) of her left breast in December 2017. She had a history of lumpectomy in May 2016 for removing the suspected cancerous tumour on her left breast. In November 2016, Mrs. M was diagnosed with a 3.7cm tumour in left breast. This diagnosis was identified when she underwent her oncology follow up. After this diagnosis, Mrs. M underwent radiation therapy followed by the chemotherapy for 3 weeks. But, in December 2017, she was again diagnosed with multiple separate painful masses in the same breast. This was troublesome for Mrs. M to accept. But, she received a biopsy that gave the confirmation of adenocarcinoma. The oncology team did deep analysis of her case and within 2 weeks of the diagnosis the team decided to conduct a modified radical mastectomy (MRM) of her left breast to be done after 5 weeks of chemotherapy. This decision was taken after consulting and taking the consent of Mrs. M and her family members. As she was a widow, her daughter was the key guardian and key member involved in this decision making. The MRM decision is most efficient in this case because is the standard surgical treatment for the early stage breast cancers spread to lymph nodes. It is as effective as the traditional radical mastectomy, but most efficient as it takes less toll over a woman’s appearance (Xin, Zhang, Zhong, Liu, Zhang, Zhang & Tang, 2017).

Patient safety is the most essential component within the quality healthcare. The surgical interventions are complex and demands increasing technical skills expertise. The human being is prone to error and scientific training is not sufficient to assure the desirable results. It is essential to develop the non-technical skills like teamwork capabilities Bergström, Håkansson, Stomberg & Bjerså, 2017). Mrs. M’s surgical journey has been efficiently managed by the strong team work and consistent communication of the team members all through the surgical stages. The team communication is reflective of team cognition and their awareness about patient’s health from time to time and capability to identify the team errors immediately with effective team work and proficiency (Xin et al., 2017). There is strong link between team work and communication for positive surgical outcomes. The communication breakdown is capable to result in greater information loss and the degraded information sharing will occur in the surgical team (Bergström et al., 2017). This can degrade the surgical outcomes and patient safety. One such communication error has occurred during this surgical process, but was identified on time with the good team work and management skills of the surgical nursing team and the error was eliminated and the patient harm was avoided. It is appreciable to define that briefing prior every stage of surgery helped in better management through preoperative, intraoperative, and postoperative phases (Ignatavicius, Workman & Rebar, 2017). During every operational step, the surgical nursing team used to refer to the surgical safety and procedural checklist and used to debrief at the end of the list. Every member in the surgical team from doctor to nurse to anesthetic professional, all were communicating consistently through calls, face-to-face brief interactions, and even followed the ISBAR format (Xin et al., 2017).

Mrs. M’s actual clinical journey started when she was admitted into the Pre-operative care ward/unit. This is the crucial patient care phase as pre-operative phase is a sudden transition in patient’s life where the patient is assessed in several areas. As per Pyfer, Chatterjee, Chen, Nigriny, Czerniecki, Tchou & Fisher (2016) the assessment the most critical part in terms of the pre-operative clinical procedure as this process assists the surgical team to appropriately assess patient’s mental and physical health and to assure balance prior the surgery. The assessment also helped the preoperative unit team and the breast care support nursing team to timely identify the present or potential risks that are able to compromise Mrs. M’s safety and surgery outcomes (Rothrock, 2014). Mrs. M’s overall health was assessed. The key assessments conducted were ECG- electrocardiogram, blood tests, allergies, any past medical history, any past surgical history, airway status, and chest x-ray post admission. Next, the anesthesiologist (the physician administering the anesthesia) performed the brief physical assessment and even took and analyzed the medical history (Ignatavicius et al., 2017). The anesthesiologist was also made aware of the present medications, the allergic history, and earlier adverse reactions towards anesthesia for assessing the conditions which can determine the anesthesia choice and required precautions (Xin et al., 2017). Further, on admission into the hospital for masectomy, Mrs. M was asked to sign the informed consent form to assure that the surgeon explained in detail about mastectomy procedure and its associated risks to Mrs. M and her family (Rothrock, 2014). This was a key ethical consideration as Mrs. M was quite anxious regarding the surgery and was not doubtful. Informed consent is most central to surgery practice necessary to be obtained for mastectomy procedure (Ignatavicius, Workman & Rebar, 2017). It is not just ethically correct but it is also a legal right and must be respected no matter patient wishes at a variance. The surgical team needs to respect and upheld after the information sharing process conveying every data about her need and want for better decision making. Thus, the team improved her knowledge through images and videos and weigh up implications (Pyfer et al., 2016).

The whole surgical team including surgeon, anaesthesiologist, scrub nurse or assistant, and circulating nurse during the preoperative phase assessed her surgery comprehension. Failure to take consent could have resulted in unimportant litigations (Rothrock, 2014). Specifically, during this pre-operative assessment, the nursing team also confirmed and verified her identity and match up to the defined clinical procedure and planning the post-operative care as it is the high priority in terms of patient safety NSQHS standard 5 (ACSQHC, 2012). This phase of surgical journey was noisy and busy with several interruptions that were managed with support and knowledge of the surgical team to keep patient safety at its best. As per the comfort theory and clinical competency, the anaesthetic nurse has to be competent enough and fully aware of the core Standards of perioperative or preoperative nursing duties as defined in the Australian Statement 10.7 (ACSQHC, 2012; & Bergström et al., 2017). The anaesthetic nurse also plays the key role in managing patient’s airway and respiration prior, during and post surgery as guided by the clinical guidelines (Bergström et al., 2017).

Prior the beginning of the intraoperative phase, Mrs. M was refrained from drinking or eating at least 8 hours before the surgery which was necessary to decrease the risk of vomiting during the phase of surgical procedure. It also includes the intake of oral medications which needed in-depth discussion with the physician (Pyfer et al., 2016). The intraoperative phase began smoothly after several interruptions. This phase extends from the time when Mrs. M was admitted to the operating room, till the anesthesia administration, surgical procedure, and Mrs. M being transported to the postanethesia care unit (PACU) or the recovery room (Ignatavicius et al., 2017). During this phase, the nurse plays the key role of Mrs. M’s chief advocate. Mrs. M was provided complete security by acknowledging that she was provided protection all during this procedure (Rothrock, 2014). The entire intraoperative phase promoted the asepsis principle, homeostasis, hemostasis, and safe anesthesia administration. It is true to state that the whole surgical journey of Mrs. M was following the ethical issues of beneficence (doing good), and non-malfeasance (avoiding harm). The surgical team consulted Mrs. M prior the surgery for every related fact and decision that also included her family members (Pyfer et al., 2016). The surgical team did the best competitively and keeping Mrs. M and her family up-to-date about her health and needs (Xin et al., 2017). Since the Hippocratic Oath, the principle of non-malfeasance has been enshrined in medical practice. The surgical inherent risks were managed efficiently. The team did not violate any medical rule (Rothrock, 2014).

When Mrs. M was admitted to the Operation theatre, she was cross-checked for the identity and related data conducting paperwork as defined in the pre-operative checklist. Suddenly, it was found in the handover by the day surgery nurse that the patient surely signed the informed consent, but she was still not fully satisfied with data and had a wish to speak to the surgeon (Xin et al., 2017). This could have occurred as the medical error, but, the nurse identified it through properly prepared nursing handover and was resolved on time. This is again an aspect of good team work and communication system. The surgical nurse communicated this to the surgeon as it was important because Mrs. M was not ready to proceed with her surgery. It was also found that the surgical nurse was also worried about the potential of wrong procedure and the wrong site surgery. As per World Health Organization (WHO) in 2004, the Surgical Safety Checklist was made a global mandatory initiative for promoting the patient safety during surgery. This checklist has been well adapted and adopted by several nations globally like New Zealand and Australia. As per the recommendations given by the Australian College of Operating Room Nurses (ACORN, 2018), the hospital system needs to assure effective systems in place to assure the medication and surgical errors avoided, and wrong site surgery probability. This was the reason that the surgical nurse consulted with the surgeon for speaking calmly and deeply with Mrs. M to assure the achievable informed consent with correct surgical process performance (Ignatavicius et al., 2017).

Mrs. M was then transferred to the operation theatre after attaining the informed consent and the operational checklists were accomplished as per the hospital policy (Waisel, 2016). The anesthetic team received Mrs. M. But, just before Mrs. K was to be received by the surgeon in the operating room, Mrs. M became anxious as the vital stats assessed just before the surgery represented abnormal heart rate and hypertension with sweating (Raichle, Osborne, Jensen, Ehde, Smith & Robinson, 2015). Mrs. M also became emotionally unstable with irritable behavior when she was being communicated by the anesthetic team. She was answering aggressively. Anxiety is quite normal in patients’ prior surgery. Anxiety needs to be managed because it has physiological effects that can result in tachycardia, hypertension, and temperature rise (Yekta, Sadeghian, Larijani & Mehran, 2017). The nursing team consulted the surgeon and allowed Mrs. M’s daughter to sit with her prior surgery for about 5-10 minutes. Even the senior surgical nurse counseled Mrs. M involving her daughter. After 15 minutes, she was relieved and even her vital stats became stable (Waisel, 2016). Further, the surgeon identified the patient details and planned procedure matched the consent, and her VTE prophylaxis measurements were applied (Broom, Broom, Kirby & Post, 2018). The VTE prophylaxis measures the patient in terms of anti-embolism stockings, intermittent pneumatic compression device, or foot impulse device. Even she was preoxygenated for about 5 minutes with slow administration of 150mg Diprivan. With smooth process, the test ventilation with facemask through oral airway insitu was done (Yekta et al., 2017). Recuronium 6mg was also administered for general anesthesia for providing skeletal muscle relaxation during mastectomy surgery. This level was deepened through the application of Sevoflurane and Nitrous oxide (Broom et al., 2018).  This step was followed by Largngoscopy by revealing epiglottis tip. From the left side of the nose, the 6.0 cuffed Portex endotracheal tube was inserted into the trachea with the usage of bronchoscope. The intubation process was successfully attained due to effective surgical team work and efficacious two-way communication (Raichle et al., 2015).

The surgical team also paid attention to the potential of the surgical site infection or the potential of surgical sepsis. The breast surgery needs to be as cleanly performed as possible. It is the duty of the surgical team to avoid the surgical site infection by adhering towards the principles of asepsis which are specified by ACORN (2018). Asepsis is to be maintained in Mrs. M’s case. It is defined as the absence of infection or infectious material. The surgical asepsis is defined as the absence of every microorganism in any form of invasive procedure (Allegranzi, Zayed, Bischoff, Kubilay, de Jonge, de Vries & Abbas, 2016). The sterile technique was efficiently used by the surgical nursing team to make every surgical equipment and area disinfected and free from the microorganisms. The sterile technique is most essential practice in the operating rooms (Berríos-Torres, Umscheid, Bratzler, Leas, Stone, Kelz & Dellinger, 2017). This is also usable when the sterile procedure is performed at the bedside like inserting the tubes and intravenous. The sterile technique is to be used always when the skin integrity is accessed, broken, or impaired (like plausible surgical incisions in Mrs. M due to mastectomy) (Allegranzi et al., 2016). This technique prevents surgical site infections (SSI) which is a preventable surgery complication. This occurs in the surgery area. The surgical asepsis principles were followed by the surgical team as defined by the Association of periOperative Registered Nurses (AORN) (ACORN, 2018). The principle checklist was followed and communicated to all team members. Prior the principle follow-up, the surgical team followed the safety considerations of hand hygiene, wearing appropriate PPE (personal protective equipments) to reduce microorganism transmission, and reviewed the hospital procedures for sterile technique before beginning invasive procedure (Berríos-Torres et al., 2017).

The circulating nurse played the efficient role in this process. The circulating nurse is the one who responds to the requests of the surgeon, and anaesthesiologist, obtains supplies, and also delivers the supplies towards the sterile field. The circulating nurse is also responsible for carrying out the nursing care plan and communicating the needs (Rothrock, 2014). Commercially packaged sterile supplies were used, non-sterile objects were kept at distance, all the gloves and equipments to be used during surgery were kept above waist level (Allegranzi et al., 2016), contamination was avoided, all the surgical objects were placed inside the sterile field and away from 1-inch border, and movement in and around the sterile field in the operation theatre were not compromised (Ignatavicius et al., 2017). The surgical room traffic was also kept minimum. To prevent the factors contributing to SSI, Mrs. M’s was given the interventions like administering prophylatic antibiotics (Broom et al., 2018). These antibiotics were necessary prior the surgical procedures to reduce the risk of perioperative infection. These antibiotics inhibit proliferation of microorganisms within internal systems (Broom et al., 2018).

The mastectomy surgery was completed effectively and the step of “Sign out” commenced as the necessary part of the surgical safety Checklist (Ignatavicius et al., 2017). The circulating nurse was at the forefront confirming the follow up with every member of the surgical team involving the discussion about involved members, surgical procedure’s name & requirement, correct surgical count, and even labelled the specimens correctly (Pyfer et al., 2016). It was notified that during the time out, this circulating nurse rushed out of the time out and was quite dismissive because of her long-shift with no break. Mrs. M was reversed efficiently and safely from her anaesthetic level (Bergström et al., 2017). Both the anesthetic nurse as well as the anesthetist was happy when they were transferring Mrs. M to the post anaesthetic care unit (PACU) (Bergström et al., 2017).

After the surgery, Mrs. M was shifted to PACU (recovery room) where she was given comprehensive care from the experienced clinical staff monitoring her recovery from anesthesia. The nursing staff members were dutiful to monitor her vital signs, temperature, and signs of complications (Rothrock, 2014). The staff on duty was also responsible to check the surgical drains and incisions with regular check over the intravenous infusions. Mrs. M’s urine output also needs regular observation to define her actual fluid intake and output (Steyaert, Forget, Dubois, Lavand'homme & De Kock, 2016). Her body positioning comfort is most essential with pain medication as after mastectomy, she will be in pain which will disturb her positioning comfort (Ignatavicius et al., 2017). For better post-anesthesia recovery, the nursing staff instructed Mrs. M to perform moving and breathing exercises. Once the anesthesia wears off, it was probable that Mrs. M report pain in and around the surgical site and incision and for this the medication was prescribed (Gosai, Patel, Patel, Umarania & Patel, 2015). The drainage tube was placed in Mrs. M’s breast for draining fluid and blood that accumulates during healing (ACORN, 2018). It was to be removed in a week or two according to her recovery. This drainage tube was consistently monitored and recorded to keep track of her internal health and healing process (Steyaert et al., 2016). Along with this, the surgeon prescribed antibiotics to Mrs. M till the intravenous remains in. She was on IV until she was able to tolerate fluids by mouth (Bergström et al., 2017). Even the surgery resulted in tightness and muscle soreness on left side where mastectomy was done and this made it complex for Mrs. M to move her arm. The physio-therapy expert nurse was made to support Mrs. M for better support to her left arm and to keep it elevated to avoid edema (swelling) (Gosai et al., 2015).


It is quite evident after this analysis that if the patient is adequately prepared physically and psychologically, and the healthcare guidelines and policies are followed, this lowers the postoperative complications which results in the quick patient recovery. The patient who has undergone mastectomy needs assistance for several hours post anesthesia wears off. The surgical team responsible for Mrs. M was highly efficient and clinically trained in handling the perioperative care and outcomes. It is clearly evident that the nurses play the powerful role in providing safe care to patient undergoing surgery due to their extremely close relationship with patient.


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