Thursday, Jul 17, 2014The Straits TimesBy Ian PohSINGAPORE - 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.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 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, 2014ELAHA INDIVIDUAL WRITTEN ASSIGNMENTIntroductionLess 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. Main bodyThe 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 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 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 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)REFERENCESRuth, C. A. (2001, January). Nursing Negligence. Retrieved from http://ccn.aacnjournals.org/content/23/5/72.fullAccessed on 10th August 2014Calvin, S. (2011, 12th 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 10th August 2014

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