Critical Analysis Essay of a Case Study on Professional Errors in Nurse Practice

This essay provides a critical analysis of professional errors in nurse practice in the case of Patient A which lead her to mortality and also suitable legislation which can be implemented in the case of an individual.

Being a Professional
Nurse

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
CONCLUSION................................................................................................................................3
REFERENCES................................................................................................................................4

INTRODUCTION
The process of nursing involves significant steps which are assessment, diagnosis,
planning for outcomes, interventions and also evaluation of patients that have been considered as
core and essence of nurse effective practice (Starr, 2017). These effective practices of health
practitioners can able to deliver quality of services and palliative care to service seekers. The
effective practices includes collecting constant input and feedbacks from individuals and their
families are compulsory factors, which can provide a progress report of patients, this process is
also well known as evaluation period of service seekers. Whereas, occurrence of errors in the
process of evaluation of patients contributes negative influence on individual health factor which
can promote mortality of a patient. The professional errors prevailed due to factors such as
shortage of workforce, lack of quality of services etc. This essay underpins critical analysis of
professional errors in the nurse practice in the case of Patient A which lead her to mortality and
also suitable legislation which can be implemented in the case of an individual.
MAIN BODY
Case scenario
This essay delineate a case study was Patient A which is explained in brief below. On 5th
January 2013, Patient A who was 81 years old, reported problem of breathlessness and short
breathlessness from two days. On the examination of her lungs, GP observed that she was
dealing with fine crepes (bacterial infection) at the base of both lungs. GP asked her to have
clinical review after two days. The primary treatment which was given to Patient A was
commenced oral Lasix. On January 6th 2013, Patient A visited local hospital complaining again
in regards with shortness of breath. On 7th January, VMO (Visiting Medical Officer) reviews
condition of Patient A and asked for chest X-ray and blood tests. Whereas On 8th of Jan, Patient
A diagnosed diarrhoea and also right sided tenderness of individual's abdomen and he
recommended perfusion lung scan. On January 9th, Patient A reported dizziness. It is coincide
with an AF, rate of Atrial fibrillation (AF). On 10th VMO, reported Patient A, is depressed and
anxious. The VMO asked staff to mobilize him and should develop planning of her discharge at
1021 hours. Meanwhile, an individual felt unwell again and refused to eat. She seemed pale and
grey. On January 11, Registered Nurse, John, he read progress notes of Patient A, and in the
response, she reported, hospitals were not equipped to provide proper care to Patient A. She had

continual diarrhoea and dehydration. Tragically, Patient A died and the doctor stated that
primary cause of death was Septicaemia.
In this initial step, is to determine professional errors in the case of Patient A. As per the
case of Patient A, there are multiple professional errors such as lack of coordination within nurse
practitioners, lack of knowledge and skills of health practitioners, decay of quality of care and
services, which contributed in her mortality. Over time, the code of ethics, NSQHS, NMBA and
NSW are being considered to work in an effective way to provide best services and care to each
patients (Artioli & et. al., 2017). According to these considered standards, nurse practices should
be associated with compassion and respect for inherent dignity, worth as well as unique
attributes for individuals. In the case of Patients A, she was dealing with issues of short
breathlessness from two days, and through initial diagnosis it had been identified that she had
signs of bacterial infection at the base of lungs.
In medical field it is well known as fine crepes (Grindrod, 2021). Ethically, it was an
emergency to provide immediate treatment to an individual which can help to prevent initial
stage of primary cause of death (septicaemia). Rather than admission of Patient they decided to
give oral Lasix to patient, to treat issues of breathing. Thus, the first professional error can be
conclude as clinical decision making in case of Patient A. It is also a clinical error, according to
respective journals, it has been studied that nurse practitioners should implement their clinical
decision making skills at the time of consultation of patients, in order to attain effective
consultation notes (Mockler, 2020). Also, respondents asked to Patient for clinical review after
two days which promoted infection to expand in lungs. Studies determined that oral Lasix
generally works for edema which is caused by heart failure, kidney failure and so on (Quality of
Health Services in New South Wales - a framework for managing - issued 1999).
Most common symptom of edema is shortness of breath and swelling in arms, legs and
abdomen.
According to NSQHS, Comprehensive Care Standard, it aims to ensure that individual
can attain comprehensive health care that have potential to meets needs of patient (The NSQHS
Standards, 2019). Also it focuses to ensure that the risk factors of harm for individual during
health care are being prevented and managed by the help of considered strategies (Haines & et.
al.,2017). Studies consider as it integrates individual care procedure to acknowledge needs of
patients and to prevent harm. This determined NSQHS standard was not preceded by nurses in

the case of Patient A. Furthermore, another professional error that is determined by going
through the case study is identified that there was no use of antimicrobials for the administration
of infection.
According to Preventing and Controlling Infection Standard (The NSQHS Standards,
2019), the individual should be provided antimicrobials medications, if the respondents
identified presence of fine crepes in lungs at first diagnosis of patient. Another professional error
can be conclude as medication error in the case of Patient A (Xiao & et. al., 2017). As per the
standard, medication safety standard of NSQHS, aims to guarantee that practitioners should
safely prescribe, dispense, administer relevant medicines as well as monitor use of drugs. Here,
in the case Patient A, the antimicrobials drugs can be termed to be effective as they can prevent
bacterial infection in organs.
Moreover, individual reported that she is suffering with Diarrhoea and tenderness of
abdomen which are another signs and symptoms of septicaemia, which was completely
neglected by respondents in the case of Patient A. In contrast, VMO stated as Patient A is
depressed and anxious and asked nursing staff to mobilize. Due to phase of Septicaemia, Patient
A refused to eat and drink , as nature of infection attacks on the bloodstream of individual.
Through this action of VMO, another standard which was not being followed by GP, as NMBA
standard 6, which is “provide safe, appropriate and responsive quality nurse practice”
(Registered nurse standards for practice, 2021). In this, the registered nurses are associated with
the terms and conditions which is to provide comprehensive safe, quality of practice in order to
attain mutual goals and positive outcomes for individual. These are also reasoned as responsive
in regards with fulfilling needs and demands of service seekers.
I have worked in couple of hospitals as a nurse practitioner. Through my practice I have
learned how to investigate individual and management of treatment as per their symptoms of
illness. I always read first diagnosis report and progress report of patients carefully in my
practice. This will help me to determined accurate treatment and medications for straight illness
of patients. In the case of Patient A, it was identified on first day that individual had lung
infection as they neglected this symptom. In my opinion, I would have asked to Patient A, to get
admit in care centre immediately and would provided primary treatment as antibacterial drugs to
prevent her infection.. I have learnt how to attend any emergency case and requirements in

regards with admission of patients. In the case of Patient A, it has been observed that there was
lack of assistance and quality of care provided by health practitioners.
Addition to this, in the case of Patient A, there was no use of medical tools and
technologies that can help to attain accurate root cause of disease. According to my practice, I
have understood that a good use of medical tools and technologies can work effectively to
administer the heath of individuals. The lung infection can be administer through several test
such as Lung Biopsy, oximetry can be effective intervention which could provide a better result
for identification of infection (Ritchie & et. al., 2017). In my practice, I will follow up with test
of infection, which can represent he seriousness of illness. Through this practice, I have also
achieved learning of person centred care which should be provided to Patient A in order to cope
from illness. I have attained understanding to mobilize an individual, if he or she is feeling
drowsy. It can help me to establish trust and empathy with patients, so that they can trust services
which are being provided to them by care centres. I have learnt to communicate patients
effectively that can help me, to evaluate their medical reports accurately. Through effective
communication, I would have recorded accurate details of Patient A, that could help me attained
information precisely.
CONCLUSION
Overall, it has been determined that nurse practice is associated with multiple processes.
In order to provide best quality of care and services to patients, they should fulfil each
requirement of patients. As it has been seen in the case of Patient A, due to professional errors,
she lead to mortality. There are standards which are considered by government to improve
services of health practitioners and organisation that can also help to minimize mortality of
population. The considered standards are NSQHS, NMBA and NSW which highly aims on the
improvement of services and they focus on the satisfaction of patients. Prevalence of
professional errors while providing services to individuals can able to considered as barrier in
effective practice of nurse practitioners. Hence, these errors can impact negative influence on the
health of practitioners. According to my self-analysation, use of medical tool for identification of
accurate illness may help to attain accurate result.

REFERENCES
Books and Journals
Artioli, G., Foà, C., Cosentino, C., & Taffurelli, C. (2017). Integrated narrative nursing: a new
perspective for an advanced assessment. Acta Bio Medica For Health Professions. 88(1).7-17.
Xiao, S., Widger, K., Tourangeau, A., & Berta, W. (2017). Nursing process health care
indicators: a scoping review of development methods. Journal of nursing care quality. 32(1). 32-
39.
Sapkota, A., Poudel, U. K., Pokharel, J., Ghimire, P., Sedhain, A., Bhattarai, G. R., ... & Tulza,
K. C. (2019). Factors associated with job satisfaction among graduate nursing faculties in
Nepal. BMC nursing.18(1). 1-10.
Starr, L. (2017). Disciplinary action for failing to report an error. Australian Nursing and
Midwifery Journal.
Barnes, C., Hauck, Y., Mabbott, K., Officer, K., Ashton, L., & Bradfield, Z. (2021). Influencers
of women's choice and experience of exclusive formula feeding in hospital. Midwifery. 103.
103093.
Haines, V., Anderson, J., & Burke, B. (2017). Women's health in India. Australian Nursing and
Midwifery Journal. 25(4). 38.
Mockler, N. (2020). Teacher professional learning under audit: Reconfiguring practice in an age
of standards. Professional Development in Education. 1-15.
Ritchie, U. C., Turner, S. C., & Field, C. (2017). Development and utility of a medication self‐
assessment tool for community‐based healthcare services. Journal of Pharmacy Practice and
Research. 47(2). 140-146.
Grindrod, A. (2021). Dying with disability: a disability and palliative care intersectoral
partnership framework. Research and Practice in Intellectual and Developmental Disabilities, 1-
14.
Online sources
The NSQHS Standards, 2019: [Online] Available Through
<https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard>

Registered nurse standards for practice, 2021: [Online] Available Through
<https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-
standards/registered-nurse-standards-for-practice.aspx>
Quality of Health Services in New South Wales - a framework for managing - issued 1999:
[Online] Available Through <tps://www1.health.nsw.gov.au/pds/Pages/doc.aspx?
dn=PD2005_585>