NUR3201 Case Study Coroner's Court Assessment Answer

Introduction

The Queensland Coroner's Court investigated the 2014 preventable death of 32-year-old SM. In Queensland hospital SM had elective surgery for cerebral palsy. Despite the doctors' best efforts, SM died 24 hours after surgery. SM's death was preventable, according to the Coroner. The study found deficient assessments, documentation, communication, and care escalation contributed to the outcome. This case study emphasises the significance of early deterioration detection and care escalation, especially in vulnerable patients with complex demands. The Queensland Coroner's findings recommended improving patient safety and preventing such occurrences (Queensland Court, 2022). Nurses are also vital to patient care (Flinter et al., 2017).The case study details SM's July 7, 2014 death at a large regional hospital. On July 1, 2014, the hospital's ER admitted SM with a perforated appendix. After a laparoscopic appendectomy, he developed four-quadrant peritonitis, which necessitated appendix removal. Deep vein thrombosis and pulmonary embolism killed SM. The report will highlight the identification of the risks, and issues related to the case study and documentation of the care that nurses. In addition to this, it will focus on the roles and responsibilities of registered nurses along with the synopsis of the risk strategies.

Issues Introduced

One of the key difficulties in the case study is the absence of enough staffing at the healthcare facility. This led to a situation where the registered nurses on duty were overwhelmed with their workload and unable to provide timely and effective care to all patients (Haddad et al., 2017). Another issue is the failure to assess and monitor the patient's vital signs and clinical status. Because of this, the patient's worsening condition was not recognised right away, and the necessary interventions were not started right away. Another issue introduced in the case study is the breakdown in communication between the registered nurses and the healthcare providers. This resulted in a delay in the recognition of the patient's deteriorating condition and the beginning of relevant measures (Elliott & Endacott, 2022). The documentation of care provided to the patient was inadequate, with missing entries in the patient's medical records. This made it difficult for healthcare providers to understand the patient's clinical course and make informed decisions about their care. There may have been inadequate training provided to the registered nurses on how to recognize and manage deteriorating patients (Mutshatshi et al., 2018). This may have contributed to the delay in the recognition of the patient's deteriorating condition and the initiation of appropriate interventions.

Analysis

The importance of the registered nurse's involvement in the identification and escalation of care is highlighted by the numerous lost chances to identify and manage patient concerns in this case study (Massey et al., 2016). First of all, the patient's deteriorating condition was not picked up during the initial assessment, which was a missed opportunity. In the case study, SM died because acute deterioration was missed. The Coroner's case analysis determined that the registered nurse missed the patient's deteriorating condition during the initial assessment. The nurse didn't thoroughly assess the SM’s vital signs and symptoms, which could have revealed worsening. His health worsened, and despite resuscitation efforts, he died. This tragic occurrence highlights the registered nurse's role in recognising and responding to acute deterioration, as well as the importance of regular evaluations, effective communication, and documentation to optimise patient outcomes (Brekke et al., 2019). Second, there was a dearth of communication regarding the patient's status between the medical staff and the registered nurse. The registered nurse should have escalated the patient's care to the medical team when they noticed the patient's condition was deteriorating and documented this communication in the medical record (Anton et al., 2021). Thirdly, the patient's condition and the care given weren't adequately documented. The registered nurse had a duty under both the law and professional ethics to record the patient's vital signs, symptoms, and treatments in the medical file. This documentation would have offered essential information for other healthcare providers to use in the care of the patient (The Royal Children’s Hospital, 2023).

The registered nurse must perform regular assessments to spot any indications that the patient's condition is getting worse. These continuing evaluations must be thorough and all-encompassing, taking the patient's overall health into account. The continual assessments are crucial for the registered nurse to take into account in the recognition of worsening (Toney-Butler & Unison-Pace, 2018).Regular neurological evaluations should be performed by the registered nurse to keep track of the patient's level of awareness, cognitive ability, and mental state. This can help detect any changes in the patient's neurological condition that may suggest worsening. To track the patient's degree of pain and reaction to pain management measures, frequent pain evaluations should be carried out. By doing so, it will be easier to spot any changes in the patient's pain condition that might point to deterioration. The registered nurse should also conduct regular respiratory assessments to monitor the patient's breathing patterns, oxygen saturation levels, and the presence of any respiratory distress. This can assist in identifying any modifications in the patient's respiratory condition that can point to worsening (Nicolò et al., 2020). To make sure the patient is properly hydrated and to spot any imbalances that might suggest worsening, the registered nurse should also keep an eye on the patient's fluid intake and output as well as electrolyte levels. The registered nurse must take the patient's overall health state and any comorbidities into account in addition to these ongoing evaluations.

For the treatment of SM, a thorough and all-encompassing patient evaluation is essential for spotting potential hazards and making sure the right therapy is given. Along with physical health, this examination takes into account psychosocial, emotional, and cultural aspects. To create a successful care plan, a registered nurse must take all of these facets of the patient's well-being into account. The standard of care given to patients can also be impacted by human factors like workload, exhaustion, and stress (Forstag et al., 2018). In SM's situation, the busy environment of the ward, the high patient load, and the lack of support may have led to missed opportunities for escalation of care. The registered nurse must be aware of these issues and take action to lessen their negative effects on patient care (Raeisi et al., 2019).To make sure that all healthcare professionals are aware of the patient's condition, treatment plan, and any changes to their status, effective team communication, both written and verbal, is imperative. By communicating effectively, mistakes, omissions, and duplication of effort that could harm patient care are reduced. Communication problems between various healthcare practitioners in the instance of SM may have led to missed chances for care escalation. The integration of all relevant information, including patient assessments, laboratory results, and consultation with other healthcare practitioners, is necessary for effective decision-making in the delivery of care. To achieve the best outcomes for patients, registered nurses must employ critical thinking abilities to assess this data and make prompt, appropriate judgements (Fakhr-Movahedi et al., 2016).Overall, providing high-quality treatment for patients like SM requires a thorough and holistic patient assessment, an understanding of human aspects, good team communication, and solid decision-making. These factors can help prevent adverse events and ensure that patients receive the best possible care.

Synopsis of Risk Strategies

According to the case study, there were missed opportunities to identify and respond to the patient's worsening condition. To avoid these risks, the following techniques could be implemented. First is assessments of the patient that are both regular and systematic. Licensed nurses can ensure that their patients receive regular and systematic evaluations, including monitoring of their vital signs, evaluations of their respiratory systems, and evaluations of their neurological systems (Sapra et al., 2022). Second is clinical decision-making tools, such as early warning scores, which can be of assistance to registered nurses in the process of determining which patients are in danger of experiencing a deterioration in their condition. They can quickly identify patients who require urgent intervention and escalate their care for those patients by using these tools (Oh & Sok, 2022). Third, effective communication is critical in eliminating missed opportunities in diagnosing and responding to acute deterioration, and it is one of the most important factors in ensuring patient safety. To guarantee that other members of the patient's healthcare team, such as physicians, allied health professionals, and other nurses, are kept up to date on the patient's condition and any changes in their status, registered nurses have a responsibility to ensure that they communicate effectively with the other members of the patient's healthcare team (Fakhr-Movahedi et al., 2016). Fourth regular team education and training sessions can help healthcare teams become more knowledgeable and proficient in recognising and handling acute deterioration. Robust documentation is vital in ensuring that there is clear communication between healthcare personnel and that patient treatment is accurately recorded. It is the responsibility of the registered nurse to ensure that all evaluations, observations, and interventions are documented in the medical record of the patient in a timely and accurate manner (Merriel et al., 2019).

Health Service Work with SM Family

Partnering with consumers is a vital requirement in ensuring safe and high-quality healthcare. The guideline demands healthcare providers engage and involve patients, their families, and carers in the care process, decisions, and planning. In the instance of SM, the healthcare provider could cooperate with SM's family to prevent another such incident by applying the following strategies. First, the healthcare service could involve SM's family in preparing a care plan that takes into consideration SM's particular needs, preferences, and goals. The care plan could include SM's medical history, medications, allergies, and other pertinent information (Ajibade, 2021). The plan may also contain SM's care preferences, such as communication style and cultural needs. It will also assure compliance with the National Safety and Quality Health Service Standards-working with Consumers Standard, which emphasises working with patients and their families in care (Ajibade, 2021).By doing this, it will be made sure that SM's family is informed about the care and assistance SM requires and how they can help to provide it. Second, the healthcare service might design a communication strategy that includes regular updates to SM's family regarding his care, treatment, and progress. The care team will gain more trust and confidence as a result, and SM's family will be able to give feedback and voice any issues they may have (Wang et al., 2017).Third, the healthcare service could provide education and training to SM's family about SM's condition, treatment, and care needs. This will enable SM's family to better understand his condition and how they can best support him, as well as recognize signals of worsening and respond properly. Fourth, the healthcare service might make peer support groups and counselling available to SM's family. As a result, the family SM will be better able to support SM and manage the stress and emotional effects of SM's condition (Merriel et al., 2019).

Conclusion

The registered nurse plays an important role in the healthcare system. The case study of a patient who passed away due to the carelessness of the nurse. There were several identified reasons for the gaps in the responsibilities and roles of the nurses. The report identifies several issues that contributed to the healthcare system’s failure, including understaffing, failure to assess and monitor the patient's condition, breakdown in communication between healthcare providers and registered nurses, and inadequate documentation of care. Human variables also impact the patient’s health and play a role in the responsibility of the nurses. The research emphasises the relevance of registered nurses in detecting and escalating patient concerns and proposes doing continuing evaluations to spot any signals that the patient's condition is getting worse. In addition, the report highlights the value of registered nurses in identifying and escalating patient concerns. To devise an effective treatment strategy, the report suggests conducting a comprehensive patient assessment that takes into account the individual's physical, psychological, social, and cultural characteristics.

References

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Flinter, M., Hsu, C., Cromp, D., Ladden, M. D., & Wagner, E. H. (2017). Registered Nurses in Primary Care: Emerging New Roles and Contributions to Team-Based Care in High-Performing Practices. The Journal of ambulatory care management, 40(4), 287–296. https://doi.org/10.1097/JAC.0000000000000193

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Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of patient handover process in healthcare services: A systematic review. Journal of education and health promotion, 8, 173. https://doi.org/10.4103/jehp.jehp_460_18

Sapra, A., Malik, A., & Bhandari, P. (2022). Vital sign assessment. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553213/

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Wang, Y. Y., Wan, Q. Q., Lin, F., Zhou, W. J., & Shang, S. M. (2017). Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. International journal of nursing sciences, 5(1), 81–88. https://doi.org/10.1016/j.ijnss.2017.09.007

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