A case study of SM is presented, the patient age identified is 32 years of age. Upon analysis, there are several instances found which have led to the death of the patient. The medical history suggested that the patient was admitted to the hospital in the emergency department. Upon analysis of the patient, it has been identified that the patient has been diagnosed with acute appendicitis. At the time of surgery, the appendix was perforated and it was removed from the abdominal cavity, however, it has become infected. A proper clinical review has been carried out, and some findings were noted, these are: there was a failure to complete early warning observation, the patient was present with low oxygen saturation and in the later stage also oxygen level was not taken care of. Other than this the handover process which has been carried out is fractured and not conducted effectively. In the analysis of this case study, the National Safety and Quality in
The Healthcare Standard is being discussed, and how it could have been applied effectively. Other than this the situation needs to be analyzed effectively, and the findings should be presented effectively.
There are several issues which have been identified in the case study, all these issues are highly important and need to be addressed. The first issue which has been identified is the failure to completely study early warning observations. If early warning signs are not ignored then early treatment can be provided. Every observation needs to be recorded, this will help to keep a track record of all the things.
Another issue that is identified is the failure to investigate the low oxygen saturation level. Low oxygen levels in the body can affect the functioning of the body, hence, it is important to ensure that oxygen level is maintained. In several cases, if the oxygen level is not maintained the person might slip into a coma or state of unconsciousness, other than this seizures or also known as uncontrolled or unwanted movement is also noticed. Other than this brain death is also common, or when there is no activity in the brain. Low oxygen levels can cause damage to the brain, hence, it needs to be controlled (Hafen, B.B., & Sharma, 2022).
Another issue that has been identified is the use of oxygen to manage low oxygen saturation without knowing the cause or investigating the cause. It is necessary that before providing oxygen support to the patient, the cause should be studied and it needs to be evaluated.
Handover is a highly important component in healthcare, however, this has not been performed effectively in the case study. Fractured handover can affect the patient's well-being, hence, it needs to be taken care of. All the important information about the patient should be mentioned in it (Bhutta, 2022).
All these issues are present and these need to be taken care of. All these errors could have been avoided if there was adequate communication skill present. Other than the communication skills the documentation of the patient's record needs to be done effectively. It is the responsibility of the registered nurse to take care of all the important skills and information. The patient should have been taken care of effectively and all the responsibilities are handled carefully (Sheehan et al., 2021).
There is a high level of analysis that needs to be taken care of, this analysis is required as it will help in the identification of high risk. Along with it, several human factors need to be considered, in addition to it patient assessment is highly important, and decision-making, documentation, and communication are highly important. All these factors are present here and the role of RN is highly essential as they will understand the importance of all these factors. A holistic approach should be adopted, by holistic approach it means care from every aspect needs to be provided. All aspects are taken care of such as emotional, physical, spiritual, and mental. In the case presented above communication skill was a vital skill that was lacking, hence, actions and steps need to be taken to establish effective communication. When the communication channels are open, a rapport is established, this ensures that the patient shares all their problems effectively (Eriksson et al., 2018).
In the case study, the National Safety and Quality in Healthcare Standard is followed, the standard which has been followed here is: Partnering with Consumer Standard. The leaders of the health service organization aid in maintaining, developing, and implementing a partnership with the consumers. This partnership is highly important as it relates to the design, planning, delivery, evaluation, and measurement of care. All the healthcare workforce should use these systems to partner with consumers. The major intention of this standard is that the consumer should act like a partner in the process of design, delivery, management, and evaluation of services and systems. Other than this the patient should partner in their care, and it also as to what extent they choose. In the case study if the patient would have been involved in the treatment or care plan it would have saved the patient (National Safety and Quality in Healthcare Standard, 2023). The system is designed is used to support the carers, patients, and consumers so they can partner in the healthcare process. All these parameters need to be evaluated and measured on several parameters. The next action which needs to be taken is partnering with the patient in their care. The system is built based on partnering with patients in their care. There should be a system that is based on partnering with the patient for their care. It will help to provide support for the delivery of care. The patient should partner in their care and the next extent should be chosen (Farmer et al., 2018).
Several strategies need to be implemented to mitigate risk, and also some missed opportunities. The first and most important step which needs to be adopted is patient education. As the patient is been educated, they can take care of themselves. Along with this, it is essential that early interventions need to be adopted (McGowan et al., 2023). The community members should work together this will help in the upliftment of the community.
The medical community has made strides in beginning to address the impact of obstetric hemorrhage as a cause of maternal morbidity and mortality with standardized bundles outlining key elements for hospitals to address to optimize hemorrhage prevention and management. Changes in definitions, an expansion of the spectrum of causes, variation in interventions and guidelines, and lack of innovation are some of the issues that pose ongoing challenges for meaningful risk reduction (Farmer et al., 2018).
One of the most important strategies which need to be adopted is to track and incorporate the evolving industry standards. Several standards are evolving every day, it is necessary that these standards need to be taken care of. These standards will help to regulate all the health care needs, and they will address all the problems. The health policies need to be updated, these policies are essential as they will help to meet the industry standards, and along with it, it also helps to address risk. All the policies which are developed should be put online, this will allow other people to have a look at them. Other than this the employees should be trained and tested (Pascarella et al., 2021). This is an important step as it will help to have a clear understanding of the policy. When the employees are trained, it will allow them to take several steps by themselves and the chances of early intervention are highly important. All the records are kept should be kept in a detailed manner, other than this all the signs-off and policy distribution needs to be understood. When a clear understanding of the policy is developed, then effective steps need to be taken. Sign-offs need to be recorded, and it is essential, as it will help in keeping a proper track record. There are different stages of risk mitigation and these stages are: reduction, avoidance, acceptance, and transference. These stages need to be taken care of and they should be taken into consideration (Kaya et al., 2019).
In the case study, it has been mentioned that early signs were ignored, if the early signs were not been ignored then effective steps would have been taken in time and this could have been avoided. It would have provided time for early intervention, hence, it would have been effective. Another highly common risk factor was the process of handover, handover should have been done effectively as this would be like the first step towards providing treatment to the patient. Handover plays a highly effective role while treating the patient, it would take care of all the important things and holistic care needs to be provided. The major error from the side of the nurse is that the oxygen level should have been checked at a much earlier stage effectively. If the oxygen level is not maintained effectively then there are several activities which are hampered. Regular monitoring of oxygen levels is essential as certain activities entirely depend on the oxygen saturation level. One of the most important things which should have been taken care of is that at the time of administration of oxygen, the cause of oxygen administration should be known. If this cause is known then better care will be provided, and patient health will be maintained (McGowan et al., 2023).
This paper is about the case study of SM. The patient's age identified is 32 years of age. Upon analysis, there are several instances found which have led to the death of the patient. The medical history stated that the patient was admitted to the hospital in the emergency department. Several issues have been identified and these are: early warning signs are ignored, the handover process is not done nicely, and the use of oxygen has not been mentioned adequately. Since there are several issues present, risk analysis needs to be done. It is essential as it will help to understand the risk and effective steps are needed to mitigate it. There are various stages of risk mitigation and these stages are: reduction, avoidance, acceptance, and transference. All these stages need to be taken care of and it should be taken into consideration.
Bhutta, B.S., Alghoula, F., & Berim, I. (2022). Hypoxia. In StatPearls. StatPearls Publishing.
Eriksson, I., Lindblad, M., Möller, U., & Gillsjö, C. (2018). Holistic health care: Patients' experiences of health care provided by an Advanced Practice Nurse. International Journal of Nursing Practice, 24(1), e12603. https://doi.org/10.1111/ijn.12603
Farmer, J., Bigby, C., Davis, H., Carlisle, K., Kenny, A., & Huysmans, R. (2018). The state of health services partnering with consumers: Evidence from an online survey of Australian health services. BMC Health Services Research, 18(1), 628. https://doi.org/10.1186/s12913-018-3433-y
Hafen, B.B., & Sharma, S. (2022). Oxygen saturation. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525974/
Kaya, G.K., Ward, J.R., & Clarkson, P.J. (2019). A framework to support risk assessment in hospitals.International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care,31(5), 393–401. https://doi.org/10.1093/intqhc/mzy194
McGowan, J., Wojahn, A., & Nicolin, J.R. (2023). Risk management event evaluation and responsibilities. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559326/
McGowan, J., Wojahn, A., & Nicolini, J.R. (2023). Risk management event evaluation and responsibilities. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559326/
National Safety and Quality in Healthcare Standard. (2023). Partnering with Consumers Standard. Available from https://www.safetyandquality.gov.au/standards/nsqhs-standards/partnering-consumers-standard
Pascarella, G., Rossi, M., Montella, E., Capasso, A., De Feo, G., Botti, G., Nardone, A., Montuori, P., Triassi, M., D'Auria, S., & Morabito, A. (2021). Risk analysis in healthcare organizations: Methodological framework and critical variables.Risk Management and Healthcare Policy,14, 2897–2911. https://doi.org/10.2147/RMHP.S309098
Sheehan, J., Laver, K., Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N.A. (2021). Methods and effectiveness of communication between hospital allied health and primary care practitioners: A systematic narrative review. Journal of Multidisciplinary Healthcare, 14, 493–511. https://doi.org/10.2147/JMDH.S295549
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