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Critical incident Analysis

Waqar Javeed
2012028
Submitted
To
Miss Somia
Date: 22-06-2010
Shifa College of nursing Islamabad
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Context of the incident

Reflection in the unsterile dressing may be defined “the dressing in which there is no
maintenance of hygienic practices throughout procedure which is very important to
maintaining in this procedure to prevent it form further damage”. Reflective practice is a
concept used in education studies. Reflective practice is a continuous process and
involves the learner considering critical incidents in his or her life's experiences. As
defined by Schön, reflective practice involves thoughtfully considering one's own
experiences in applying knowledge to practice while being coached by professionals in
the discipline. It is commonly used in Health and Teaching professions, though applicable
to all. In the wound dressing procedure did not maintain hygienic practice and this
incident affect me. Critical incidents can prompt reflection because they highlight
something that is important to us (smith and Jack 2005). This assignment will examine
my reflection encountered on a Adult unit A3 in a Shifa International hospital Islamabad.
I will explore the good and bad I pulled from my experience. My aim is to emphasize
and summarize my reflection of learning, critically analyze this incident and also how
this affected me as a student nurse.

What happened?
During my initial assessments the patient was lying in lateral position. He has a heel of
ulcer which is very deep and containing pus and some fluid ooze from it. The Consultant
advised him to do dressing everyday. But he did not follow the advice of his doctor so the
wound condition become worse and he was admitted here in the hospital again due to
severe infection occur in the heel. The consultant performs debridement of pressure ulcer
in two day ago. Operative debridement of pressure ulcers is safe, despite the medical co-
morbidities in patients with severe pressure ulcers. Proper debridement technique may
prevent sepsis and death in patients with multiple co-morbid conditions.
http://www.springerlink.com/content/5603740lj14q34w7/. He stated that he has very
severe pain in the heel due to which he cannot put weight on his left foot. The antibiotic
medication is in progress. His consultant also order of sterile dressing every day. Then at
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1000 am the MO came in the room with sterile equipment for dressing A MO (assign
doctor in the A3 ward) was about to be performing of wound sterile dressing of patient in
the morning whose attendant were not present in the ward and also he is also a private
patient. As I was aware I had never seen this procedure done on any patient so I asked
from the MO if I could observe and assist you in the procedure and he agreed. The MO
then got very busy in the procedure during procedure. The Mo did not maintain hygienic
technique during procedure, in which he did not switch of fan, maintain privacy, and
don’t cover the tray with sterile towel. When changing a wound dressing, did not use a
clean technique then sterile technique in dressing. Don’t perform scrub hand washing and
directly put sterile gloves. When I saw this then I think that I didn’t assist the MO further
in the procedure, but the MO persist me in a de-meaning manner (reminding my student
status) that you should assist me in the procedure. During dressing he some time attach
his gloves with unsterile things. This finding alerted me to the fact that Mo did maintain
the sterile technique during this procedure. The patient’s room was directly across from
the nursing counter and door was open. I persisted that you did not maintain sterile
technique in procedure. After passing sometime I went in the counter. Suddenly my
clinical faculty arrived unexpectedly to observe me and my colleague. And then I
discussed this incident with faculty. But here I do one mistake that this incident which
happen with patient I cannot report to team leader and not recorded it in the patient note,
which came in my mind late.
My thought and feeling at the time of incident
I had very sad feelings at that time when I came across this incidence. Ethics consists of
the moral principles governing or influencing conduct (oxford compact dictionary 2007).
Many ethical issues are raised in this incident one of the most prominent is the lack of
respect shown by MO in front of me and his patient. So I will reflect upon this as a
learning experience. The qualities include the skills, qualities and attitude of individual
mentors are more important to a positive practice placement than the learning
environment (Nursing standard: May 24: vol 20: no 37:2006). I was amazed first then it
made me upset that a trained MO was doing such wrong practice and did not maintain
hygienic condition during procedure and directly harming the patient rather than
providing advantage to the patient. I was very worried about the health of patient now
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what will be happen to the patient. The MO was harming the patient health by providing
a medium of spread of infection. In this way the wound condition of patient become
worse, and pass organism to the patient through unsterile technique of dressing. The Mo
also did not behave well with me as well as with patient and also not satisfy the patient.
They do not provide care according to the need of the patient. The assigned doctor only
came for one time a round and see the dressing and patient and if patient complaint, then
the order some new antibiotic and document condition and went away. Otherwise he did
not properly assess the patient and directly ask the condition of patient form the MO. I
was aware that I begin to feel very uneasy during this incident but during discussion it
found it to maintain eye contact with clinical faculty is difficult but I maintained it during
discussion. I was relieved as y clinical faculty who offered me the chance to find a quiet
place to exchange some feedback and reflect on this incident.

Refection on incident
I felt please with my initial subjective assessment of the patient, which seemed to flow
well and was pleased that t had noted from the patient’s responses to my question that has
tendency to suffer from other infection which can be worse the condition of wound.
However during my objective assessment, I had focused on the condition of wound. The
re is deep hole seen in the wound with pus and some fluids are oozing form this wound.
The area around the wound is red, warm to touch, pain feels pain and inflammation is
present. The function of foot loss, due to this severe pain present on the heel. Although
the extremities color is pink and both dorsal pedals and posterior tibial pulses are
palpable. He also stated that he did not know how he prevents the wound from further
infection. All other finding is normal such as lung and heart sound is clear and normal.
All other remaining pulses were palpable. The vital sign are normal. There is no edema
present on rest of the body. The Hydrocolloids, alginates, or foam dressing is applied by
MO. It is used for pressure heel ulcer wound When changing a wound dressing, I know
we are suppose to remove the soiled dressing using a clean technique(non sterile gloves)
then sterile technique to put on clean dressing.. Hydrocolloids are indicated for light-to-
moderate exudates; some have adhesive backings and others are typically covered with
transparent films to ensure adherence to the ulcer and must be changed within every 1 -3
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days. Alginates, which come as pads, ropes, and ribbons are indicated for absorbing
extensive exudates and for controlling bleeding after surgical debridement. Foam
dressings are useful as they can handle a variety of levels of exudates and provide a moist
environment for wound healing. Waterproof versions protect the skin from incontinence.
Those with adhesive backings stay in place longer and need less frequent changing. It
prevents the wound from infection.
http://www.merck.com/mmpe/sec10/ch126/ch126a.html.
Don’t perform scrub hand washing (To remove transient organisms and reduce the
number of commensal organisms on the hands.) and don’t cover the tray with sterile
towel (To minimise airborne contamination). I think the MO did not know the principle
of asepis.
The principles of Asepsis have six components:
11. Hand hygiene/ decontamination
22. Personal protective equipment
33. Preparation of the patient for an invasive procedure
44. Creating and maintaining a sterile field
55. Use of safe invasive techniques
66. Creating the safe environment
I think that MO did not use properly general principle and indication.
General Principles The timing of procedures such as re-dressing wounds in a ward area
can be an important factor in helping to reduce the risk of infection. They should not be
carried out when tasks such as bed-making are taking place, due to the risk of micro-
organisms being dispersed into the air and potentially contaminating the sterile equipment
or wound. Ideally, these should be carried out at a time when the ward/home activities are
less and cleaning activities suspended. Clean, non-infected wounds should be dressed
first; colostomies and infected wounds should be dressed last, to minimize environmental
contamination and cross- infection.
Indications for Aseptic Technique
 Care of wounds healing by primary intention, e.g. surgical incisions and fresh
breaks.
 Trauma wounds/hidden cavity wounds/sinuses/deep chronic wounds
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 Suturing of wounds.
 Insertion of urinary catheters.
 Insertion, re-siting or dressing intravenous cannulae or other intravenous devices,
such as CVP lines, Hickman lines and arteriallines.
 Insertion of gastrostomy and jejunostomy tubes.
 Insertion of tracheostomy tubes or chest drains.
 Biopsies
Wound infection is the most common complication of having a wound and can slow
wound healing. Infection can spread to surrounding tissue (called cellulitis), bone (called
osteomyelitis) or throughout the body (called sepsis). These are serious complications -
so, do everything you can to follow these tips for infection control and prevent infection.
According to this POLICY FOR ASEPTIC TECHNIQUE: Aseptic No Touch
Technique (ANTT) is a standard for safe and effective practice that can be applied to
certain aseptic procedures such as intravenous therapy administration via peripheral
cannulae, wound care and urinary catheterization. It standardizes practice and rationalizes
the many different techniques currently in use. An ANTT means that when handling
sterile equipment, only the part of the equipment not in contact with the susceptible site is
handled. It is essential to ensure that hands, even though they have been washed, do not
contaminate the sterile equipment or the patient. The aim is for asepsis not sterility. The
individual healthcare professionals need to decide between sterile or non-sterile
field/gloves and simply ask themselves “can I do this procedure without touching
key-parts?”
If the answer is NO – they use a sterile dressing pack and sterile gloves.
If YES – they wear non-sterile gloves.
The principle is that you cannot infect a key part if it is not touched. A key part must only
come into contact with other key parts (i.e. syringe tip and needle hub); non-key parts
should be touched with confidence.
Always wash hands effectively
Never contaminate key parts
Touch non key-parts with confidence
Take appropriate infective precautions
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Aims of an Aseptic Technique

• To prevent the introduction of potentially pathogenic micro-organisms into susceptible
sites such as wounds or the bladder.
• To prevent the transfer of potentially pathogenic micro-organisms from one patient to
another.
• To prevent staff from acquiring an infection from the patient.
But the above mention aseptic technique doctor did not maintained By MO.
So I had acted in this way and led to further analysis on this situation. I had felt under
pressure not only because my clinical faculty came unexpected; but because I want to
ensure I had obtained as much as information as possible from the patient during
assessment, which enable me to write a CIA on this incident. I also need to manage my
time effectively and asses patient properly. In my effort during clinical I achieve my
objective and also not put patient on risk. I had passed to communicate effectively with
my patient and get enough feedback from patient during objective assessment. I had also
explained things clearly and had not rushed from the subjective to objective assessment
in order to ensure to utilize enough time which I had. This important communication with
my patient may have alerted me to the fact that an unsterile dressing should have been
worsen the condition of wound and it took a lot of time for healing. I could also have
considered carrying out the assessment during measure vital sign of patient.
The chance of discussing the incident with my clinical faculty had many value. My
clinical faculty allowed me to describe and tell her exactly how I felt both these during
and after the incident. I did not feel threatened by describing as we ha a good working
rapport and I felt able to disclose my feeling to her which helps me reflect further more
on this incident. My clinical faculty used prompt question in a supportive way to
encourage me to identify positive aspect of my practice and negative aspect of my
practice and the area that I felt could have changed. Throughout the reflective discussion
she used effective non-verbal and verbal communication sills and provided me with
constructive feedback on the discussion.
My clinical faculty highlighted the importance of always remaining close to the patient
and provided him total care to the patient. She also suggested that I had a potency to put
myself under pressure always. This discussion also made me realize the textbook
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assessment and lecture assessment are very different fro assessment on the patient. I felt
fully supported by my clinical faculty and these help me to regain my confidence.
According to principle of beneficence and maleficence the MO should always do good
work to prevent harm standard of unsterile practice, primarily address the MO use sterile
process in the provision of care that is based on sound principles and substantive
knowledge. Occasionally infection persists and leads

What did I learnt form this incident

I learnt how is essential to use the subjective as well as objective assessment to built
rapport and gain some information about patient and to use both these finding to ensure
both comfort and safety of the patient. I also learnt that it is very important to maintain
hygienic practice during sterile dressing of a wound to prevent it form the further more
infection. I also learn that during procedure it is necessary to handling carefully and
accurately, also in assessment as well treatment time. I have also learnt that the MO
should show their responsibility and try to promote care to the patient. He should take
care of patient and maintaining sterile technique in order to prevent the spread of
infection to the patient. This incident took place because of careless and negligence of the
MO, the patient was admitted to the hospital to get treatment and care as soon as possible
but due to this situation the condition of patient may become worsen.

How can I use this learning to inform my future practice?

In future I ensure you that my purpose is to make my communication with the patient
more effective by using verbal, non verbal communication and other communication
technique, this strategy should allow me to adapt a elastic approach, enabling me to adapt
my all assessments and provide care according to need of individual patient. When asking
a patient and during dressing procedure I will ensure I am close to the patient enough to
provide fulfill patient needs and ensure the practice of MO is safe or not. I am also more
aware of observation skills that clinical faculty demonstrate to allow student time to use
this in the clinical setting and encourage them to be self critical so I can built on my
strengths and addresses weakness in the clinical practices.
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References
1. http://pompi/marsden/content/contents.htm
2. http://www.erypct.nhs.uk/upload/HERHIS/East%20Riding%20PCTs/Document
%20Store/Policies/Aseptic%20technique%20updated%2021%2011%2008.pdf
3. http://www.merck.com/mmpe/sec10/ch126/ch126a.html.
4. http://endoflifecare.tripod.com/imbeddedlinks/id4.html
5. http://www.cht.nhs.uk/fileadmin/departments/infection_control/policies/Section_
G_-_Aseptic_Technique_Issue_2.pdf
6. www.hertspartsft.nhs.uk/_.../policies/.../aseptic-technique-guidelines.pdf