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Thursday, Jul 17, 2014

The Straits Times
By Ian Poh
SINGAPORE - A grandmother died from a lack of oxygen to her brain after staff
transferring her from one hospital to another did not turn on the oxygen tank after
putting her on a ventilator.
Madam Ramasamy Krishnama became unresponsive in the three to four minutes that
passed before the oxygen was turned on, a coroner's inquiry heard yesterday. No foul
play is suspected.
The 83-year-old, who had been warded in June last year at Tan Tock Seng Hospital
following a heart attack, was being transferred to Mount Elizabeth Novena Hospital
when the incident took place about a month later.
Madam Ramasamy, who had become dependent on mechanical ventilation, died a few
hours after her condition deteriorated owing to "ventilatory failure" that cut off her
oxygen supply.
A police investigation report submitted to the court noted that her vital signs had been
stable hours before the incident. She had also been alert and comfortable before being
handed over to the receiving team.
This comprised a doctor and nurse from Gleneagles Hospital - which shares a parent
company, Parkway Shenton, with Mount Elizabeth Novena Hospital - and a staff nurse
from Mount Elizabeth Novena Hospital.
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But shortly after being transferred from her bed to a trolley and put on a portable
ventilator on July 8 last year, Madam Ramasamy's level of oxygen saturation was noted
to be "unrecordable", raising concerns that it was very low.
This led the transfer team to check their equipment. One of the nurses realised that a
switch on the portable oxygen tank used to supply the portable ventilator had not been
turned on.
The oxygen cylinder switch was then turned on and the ventilator turned up to the
maximum setting, but Madam Ramasamy's condition did not improve, the inquiry heard.
She was moved back to her bed, where cardiopulmonary resuscitation was attempted
on her, but to no avail. She was pronounced dead at 9.55pm the same day.
The patient, who had a heart attack on June 13 last year, had a history of diabetes, high
blood pressure and excessive levels of fatty substances in the blood, known as
hyperlipidemia. Citing the attack and other complications, a medical report mentioned in
the police report said her heart, which could not be restarted after she went into cardiac
arrest during the incident, was "the major problem".
Given her poor health and critical state at the time, the short period of oxygen
deprivation had "probably precipitated" her death, said the report.
It added that she "would have expired in the very near future even with the best
treatment".
According to an internal review conducted by Parkway Shenton, the transfer team had
assumed that the switch was already turned on as staff had heard air gushing out when
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the ventilator was connected to the oxygen tank. They thus checked the equipment for
other problems first, not immediately realising that the cylinder switch was not on.
Madam Ramasamy left behind six children and more than 10 grandchildren.
Her family said through their lawyer Tan Hee Joek that they were deeply saddened by
her loss and await the findings of State Coroner Marvin Bay. These will be delivered on
July 30.
Adapted from the Straits Times, 2014
ELAHA INDIVIDUAL WRITTEN ASSIGNMENT
Introduction
Less than one month ago, there was a case of nursing negligence of nurses forgetting
to turn on the oxygen during patient transfer, which caused the death of an elderly
patient. The patient, Mdm Ramasamy, 83 years old was being transferred from Tan
Tock Seng Hospital to Mount Elizabeth Novena hospital when the incident took place.
She was dependent on mechanical ventilation. When the healthcare team proceeded to
obtain her oxygen saturation but it was un-recordable. A nurse then found out that the
portable ventilator was not turned on. Resuscitation efforts were performed but Mdm
Ramasamy died shortly after. She had multiple health problems such as diabetes,
hypertension and hyperlipidaemia. She also had previous heart attacks. It was also
stated in the medical report that she would have expired in the very near future even
with the best treatment. An assumption of the oxygen has already been turned on led
to this negligent.
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Main body
The three ethical principles breached in this incident were beneficence, fidelity and non-
maleficence.
Firstly, the hospital transfer team failed to double check that the oxygen tank was
switched on. By taking the shortcut, they had assumed that it was already turned on as
one of the staff had heard air gushing out when ventilator was connected to the oxygen
tank. This does not necessarily means that the oxygen tank was turned on. Second is
fidelity. The team failed to keep up with the oxygen tank safety check, ensuring that
there was oxygen despite knowing the patient was dependent on mechanical ventilation.
Lastly, it is non-maleficence. The team has caused an irreversible harm by not turning
on the oxygen.
According to the SNB code of conduct, the three areas that were breached were: Value
statement 5, providing care in a responsible and accountable manner. In this incident,
the care provided was very bad as they failed to realise the oxygen tank hadnt been
turned on.
Secondly, Value statement 6, maintain competency in care of clients. If the transfer
team were competent enough and remembered to double check the ventilator and the
tank was switched on, this incident could have been prevented. I felt that it was
unacceptable when they only found out when they couldnt obtain the patients oxygen
saturation. What if the team didnt obtain her vital signs, assuming that the patient is
comfortable and well, going ahead with the transfer to Mount Elizabeth Hospital?
Value statement 9: maintaining a practice environment that is conducive to the provision
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of ethical healthcare. During the transfer, it is possible that the crew might be under
stress, leading to the error.
Standard 1: professional and competent practice. The team did not apply their
professional knowledge, skills and judgment competently within their defined scope of
practice. The patients death was probably due to poor judgement of the nurses. It was
noted that a doctor from Gleneagles Hospital was also present, but why didnt he pick
up that the oxygen cylinder switch was not on? The team even tried to reverse the
duration of 4 minutes of patient not receiving any oxygen by turning oxygen and
ventilator up to the maximum setting.
Standard 2: accountability and responsibility. Nurses primary duty is to ensure safe and
competent nursing care to the patient. In this incident, the nurses took shortcuts in the
care provided, leading to unsafe practices. Now the team would be accountable for the
death of this patient.
My case scenario is nursing negligence. The elements to consider this as negligence
were, the transfer team making a mistake that was proved to have harmed the patient,
which was shown in the article that the patient passed away as a result. The second
element that proved nursing malpractice is the mistake that a reasonably careful nurse
would not have made in a similar situation. It could have been prevented if one of the
nurse and the doctor ensure that the oxygen switch was switched on when transferring
to the trolley and also after being transferred.
To prevent from breaching ethical principles, the organisation has to ensure all their
staffs knows the code of conduct well, and ensure that they comply to the code of
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conduct. It is important to know thoroughly about the standard set by Singapore Nursing
Board.
Secondly, ensure that proper documentation is very important. Proper and true
documentation of key matters are critical in such situation. Good and true charting is a
primary defence against liability in a malpractice suit. Never document beforehand. It is
important to note that one must not falsify documentation. Proper documentation is a
form of effective documentation, where during a transfer case. The hospital handing
over to the next team of hospital staff can get a brief overview about the patient through
documentation. (ELAHA lecture notes, 2014)
Thirdly, always question authority if one of your team members fails to act in a way of
ensuring safety and you believe that the patients life is at risk, be sure to take over what
she is doing or question her for the reason in not doing/doing. Being constantly updated
about ones knowledge is also important. When one knows his/her stuffs, she is aware
of what she is doing, the consequences of her actions and the rationale of her actions; it
is less likely that it will cause negligence. Continuing education means you are always
updating your nursing skills, keeping yourself up to date. In which you are less likely of
getting sued because you are competent in your skills and know your things.
In conclusion, I felt that nursing is a place where there are many potential liabilities that
can get us into trouble. From what Ive learnt during ELAHA lecture, even simple
matters like sub-standard care to a patient can land us in court. We must constantly
remind ourselves of the 8 ethical principles and most importantly, the code of conduct
and standard of practice being set by Singapore nursing board. Every action that we do,
we must always consider about the consequences, the rationale and how will it benefit
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or harm the patient. As a student nurse, we hold the same responsibility as staff nurses
as well, we have to be liable and accountable for the actions that we have done.
In summary, the key areas that have been discussed in the main body are three ethical
principles that have been breached in this incident which were beneficence, fidelity and
non-maleficence. It is important to have a safe practice as we would all want to avoid
any law suits involving the lapse in patient care.
(939 words)
REFERENCES
Ruth, C. A. (2001, January). Nursing Negligence. Retrieved from
http://ccn.aacnjournals.org/content/23/5/72.full
Accessed on 10
th
August 2014
Calvin, S. (2011, 12
th
October). 10 things you can do to avoid ethical breaches.
Retrieved from http://www.techrepublic.com/blog/10-things/10-plus-things-you-can-do-
to-avoid-ethical-breaches/
Accessed on 10
th
August 2014