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QUALITY, SAFETY, AND RISK IN HEALTH CARE

Student name

Date
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Introduction

Michael was a young adult aged 33 years. He succumbed to his illnesses on 11th July

2014. His headaches started on 8th July 2014. He sook medical attention from his GP but was

referred to Holy Spirit Northside hospital. Several assessments were conducted by medical

workers at the facility. A brain scan, viral meningitis evaluation and lumbar puncture test

were the tests conducted on him. He was then treated with several doses of morphine both

intravenously and by injection. His condition escalated in the early hours of July 11, 2014.

His death was due to some respiratory complications due to opiate toxicity as the inquest

findings elucidate.

Michael’s case scenario is a perfect example of the lack of professionalism among the

nurses. He was taken in the facility with an incomplete medical history record. None of the

nurses caring for Mr. Michael were concerned about his previous illnesses on sleep apnea.

Nurses, nevertheless, exercised their duty in recording his vitals during his stay at the facility.

Nurses offered Mr. Michael painkillers for his headache without really knowing what was

causing it. This made his migraines even more severe.

Nurses have a couple of roles and duties when assigned to deteriorating patients.

Using their acquired skills and expertise, nurses should be in a position to spot deteriorating

signs, namely, increased temperature, increased blood pressure and elevated breathing rates.

Nurses also have an obligation to closely monitor the patient vitals during their shifts. By

recording all patient’s vitals, nurses are able to tell when their patients are failing. In such

cases, they are able to alert the treating team for rapid response and care.

Michael’s case is a scenario where nurses disregarded some of the guidelines outlined

in both the the Nursing and Midwifery Board of Australia (2016) and the Australian

Commission's and Quality of Healthcare's requirements (2017). This essay the roles that
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nurses performed when caring for Michael while also showcasing the missed opportunities

that could have saved his life.

Critical analysis

Duties of nurses in accordance with guidelines (NMBA & ACSQH) and missed

opportunities

A certified nurse is responsible for recognizing and alerting other medical

professionals to clinical deterioration symptoms (ACSQH, 2017). Patients who are

deteriorating need be cared for (Lavoie et al., 2017). Regardless of the fact that his oxygen

saturation was at 90%, Michael's worsening condition was not addressed by registered nurse

Meadowfair. Her inability to recognize warning signs of medical deterioration demonstrates

the registered nurse malfeasance.

According to NMBA standard three requires certified nurses to maintain capability of work

rationally, commensurate with their capacity to identify and react to client condition. The

nurse's incapacity to take care of Mr. Michael demonstrates her incompetence.

Registered nurses help clients by documenting their health history, communicating ,

keeping track of their vitals, and administering medications, (ACSQH, 2017). Nurses were

tasked with these responsibilities during Calder’s stay at the hospital. Regrettably, the nursing

staff discarded these roles, and Michael died as a result. Nurse Meadowfair actually heard

Calder wheezing in his slumber over his room door, which is a indicator of breathing

problems, though, she ignores it. When Michael's oxygen saturation dropped to 79%, Nurse

Meadowfair refused to intervene (Queensland Courts, 2016).

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Communication and documentation

According to Bello(2017), how a clinician interacts, responds, and commiserates with

failing patients might substantially affect their care. Medical practitioners must be able to

openly communicate with their clients to provide them with the best possible care while also

saving money and improving overall operational service. Michael died primarily as a result of

a communication breakdown. According to the results of the inquest, Dr. Brockett does not

involve nurses in Michael's care. He goes on his ward walks by himself, unaccompanied.

Since Dr. Brockett had a proclivity for ignoring documentation, Michael's condition was

neglected, leading to his demise.

Recording a client’s vital signs is also be a form of communication. Michael’s history

is completely disregarded. As caregivers worked in change-overs, keeping track of Calder’s

health condition was crucial.  Nurse to nurse conversations during changeover was also

inefficient, even though Michael's condition was not recorded. Collaborative work among

medical personnel also did appear to be inadequate. Collaboration has significant impact

strategic-thinking. Michael's death could have been averted if the treating team had

collaborated with the nurses.

Not documenting the Calder’s health condition was considered clinical malfeasance

because it violated NMBA(2016) standards. The Nursing and Midwifery Board of

Australia (2016) guidelines highlight the benefits of effective communication in healthcare

delivery.

According to Adubi et al., (2018), recording of client’s condition makes it simpler for

healthcare professionals to communicate better among themselves.  Documentation acts as a

standard of evaluating the success of a past treatment regimen(McCarthy et al., 2019). This

data may be important in the future treatment of the patient. It helps  improve the quality of
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treatment provided to patients. Taking note of a patient's observations, according to Adubi et

al. (2018), is a safe way of keeping a record of their health records for future care.

Usage of medical files actually mitigates the deterioration of a client’s condition.

Michael had earlier seek health attention at a medical facility, though, his records had been

misplaced and couldn’t be found. This is contradictory to the ACQHS (2017). Calder had

apnea, but the doctor didn't know because he couldn't locate the patient's medical history.

Pain monitoring and assessment

Patients in a health context, according to Alvarez et al. (2017), have the right to get

the best care. According to Rostad et al., (2018), pain been one of early signs of deterioration

and is utilised by the nursing staff to evaluate the patient's condition. Dedication to excellence

enables nurses to evaluate their patients' pain continuously to monitor progress. Calder was

regularly treated with migraine opioids, as per the Queensland Courts inquest (2016). This

demonstrates that Michael's nurses skipped a critical step in the pain assessment procedure.

According to Rostad et al., (2018), pain, a warning symbol of deterioration, should be

recognized and revealed to a physician for conclusive assessment. Prior to seeking care,

Michael notified the nurse of the severity of his pain, but the nurse overlooked this detail. He

died as a direct result of insufficient pain assessment, which led to delayed action.
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Partnership

Client collaboration incorporates involving clients in recuperation, enhances routine

medical practice effectiveness(Bramhall, 2017).

Nurses invest a substantial amount of time with patients in order to get a better

picture of their conditions and to establish conversations. As per Rostad et al. (2018),

collaboration with patients aids in a better comprehension of the client’s pain and clinical

history. Collaboration could have aided medical practitioners in getting a better picture of

Michael’s pain and implementing efficient initiatives. Nurse Meadowfair was regularly

checking on Michael, this shows the importance of care continuity. Unfortunately, she

neglected to check on Michael between 0200 and 0400hrs. Michael's condition worsened

during this period. Dr. Brockett had a habit of disregarding icu reports. As a consequence,

critical details about Calder’s sleep apnea past illness were left out of his files.

Inadequate procedures for chronicling and reacting to negative outcomes, such as

Calder's, end up in medical deterioration as well as avoidable deaths ( National Commission

on Safety and Quality in Healthcare, 2016). As a consequence of Michael’s past surgery at

the very same facility, He didn’t disclosed his sleep apnea condition to the nurses. This was

due to his assumption that the medical workers had a file of his previous diseases. No

substantiation was presented that Michael's relatives briefed the treating team about his past

disease. It demonstrated a lack of collaboration between Calder, treating team and his

relatives. If Calder’s previous records had been obtained, his sleep apnea illness would have

been confirmed.

Human error and cognitive dissonance

Human mistakes is unavoidable in the medical industry (Bogner, 2018). Cognitive

dissonance may occur if errors arise as a consequence of a doctor's mistake. The doctor may
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overlook details of the screw-up that could be critical in the designing a treatment plan.

According to Helo & Moulton(2017), Thinking dissonance helps one to validate our errors.

In the world of healthcare, dissonance may obstruct one's capacity to reason..

Healthcare professionals' performance suffers if they try to justify their mistakes in order to

maintain their self-esteem. Health care providers must be held accountable for their screw-

ups in the medical field (Topol, 2019). Nurse Meadowfair’s inability to comprehend the

ramifications of her choice to offer Calder painkillers for his throbbing headaches caused

his death. Care providers must consider the potential consequences of their choices, as well as

the impact on patients.

Calder’s death as a consequence of Nurse Meadowfair's failure to grasp the

consequences of her decision to give him prescription painkillers for his headache.

Early warning scoring tools and disadvantages

Early warning tools prove critical because they help diagnose abnormalities in a

client's decline. These tools help physicians spot subtle changes in a client's vital signs,

cognitive capacity, as well as behaviors until they manifest as signs of worsening.  Early

warning indicators, according to Pimentel (2019), have a superior diagnostic capacity for

worsening clients' cases having had a major impact on clients' results by encouraging

collaboration amongst healthcare professionals.

Owing to a lack of early warning resources, Calder's aides seemed incapable of

monitoring of his condition. According to Pimentel et al. (2019), when used correctly, early

warning ratings, can predict patient decline. However, there are some flaws in these results.

Two examples are human mistakes and biased recording. Automation may be able to help

minimize these shortcomings.

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Conclusion

To sum up, many of the deterioration cases in hospital settings can be mitigated. As

described in the essay, pain evaluation is an important sign in patient deterioration. The nurse

assigned to Calder was constantly indifferent about his pain. Although medication can be

used to minimize pain, physicians should always strive to find the root cause of the patient’s

pain. Registered nurses need to be more educated on how to look for warning signs in

deteriorating patients. Through continued education, nurses could get better knowledge on

how to act in cases of clinical decline. It is also evident that through careful assessment of

patient’s vitals, medical workers should be capable of coming up with the most appropriate

treatment regimen. Mr Michael only received pain medication as a thorough assessment of

his condition was not done. As a result he succumbed to his underlying issue of sleep apnea.

Mr. Michael’s case study necessitates the provision of appropriate resources such as

the early warning tools. As discussed above early warning tools are significant in detecting

patient decline. Through automation of these tools, patient deterioration may be detected

early enough and immediate action put in place. These are oftenly referred to as high accurate

forecasters of patient worsening. Through methods discussed in this essay, deaths such as

Michael’s may be averted.

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References

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