Professional Errors in Nursing: A Case Study Analysis

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

1NURSING
Criteria 1
The case study is based on patient A, who is 81 year old and was admitted to the rural
hospital with complain of shortness of breath. VMO stated that she was anxious and
depressed though her physical alignments have improved such that VMO encouraged the
nursing professionals to mobilize the patients and asked to prepare the discharge report.
However, on the consecutive day, the respiratory rate of A raised considerable (28 to 30 beats
per minute) and the condition remain same till evening. VMO prescribed Valium and
Digoxin as the respiratory rate of the patient rose to 40 beats per minute. On the very next
day, the patient A was found pale and the VMO recommended abdominal X-ray. Afterwards,
when the patient encountered high back pain and he was unable to move. His white blood
cells also increased considerably along with the occurrence of urinary tract infection. The
doctor recommended proper antibiotics in order to reduce the bacterial infection within the
body. RN John started his shift in the after when patient reported dizziness along with
abdominal pain. Her respiratory rate was high along with high heart rate and low blood
pressure. The enrolled nurse stated patient’s condition is alarming but RN insisted that he will
check the condition of the patient only after the locum arrives. Moreover, RN though
underwent patient’s check-up but failed to record written documentation. RN telephoned
Sophie Smith, the clinical manager, but failed to raise concern about the deteriorating
condition of Patient A. Instead, John enquired her for the medication of another patient.
During filling of the ISBAR form the respondent highlighted the situation of the patient as
deteriorating and proposed for immediate interventions and notification to the family
members. The VMO arrived followed by the emergency on-call doctor after one hour and
took active initiatives to help patient to recover from dehydration. The patient however died

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during assessment performed by air evacuation team in the next morning and primary cause
of death was septicaemia.
According to the professional code of conduct published by the Nursing and the
Midwifery Board of Australia (NMBA) (2018), it nursing professionals must practice as per
the prevailing nursing standards for avoiding any mistakes and complications related to
therapy implementation. However, analysis of the case study highlighted that when the
enrolled nurse informed RN about deteriorating condition of the patient, the RN refused to
take prompt initiatives in order to manage the emergency condition. This unwanted delay in
taking medical actions resulted in further deterioration of the patient’s condition. The Nursing
Competency Standards (2018) a detailed documentation of the patient information in a
mandate as it helps the doctors and the change of shift-time nurses to get a brief over-view of
the current health parameters of the patient along with the past medical history. The main
parameters documented include the body temperature, heart rate, respiratory rate, oxygen
saturation, blood pressure, BMI pain score (if any) and oxygen saturation within the body
(Kerr et al., 2016). However, in the case it has been stated that though John assessed the
patient, he did not document any of the patients’ health-related parameter until VMO arrived
(11th of Jan 1810 hours). MET (medical emergency team) call during emergency situation
also falls under the duty of the nursing professionals. It is the responsibility of the nurse to
use critical thinking skills in order to understand the actual time for MET call (Douglas et al.,
2016). Apart from this use of effective communication skills with senior colleagues and other
healthcare physicians must be initiated in order to handle the emergency situation better
(Gausvik et al., 2015).National Competency Standards by NMBA (2018) also given
importance to effective communication skills and use of critical thinking skills in order to
highlight the clinical priority and take appropriate action for improvement in patients’ health.
However, John lacked effective communication skills because he bought no reference to the