Report on Leadership and Governance for Medical Practice: A Case Study on Cardiac Arrest during Gastroscopy

This report discusses the guidelines that need to be followed by medical practitioners to save patients, oral assessment tools and education for nurses, and quality improvement recommendations for hospitals. It also includes a case study on a 46-year-old lady who died due to complications during gastroscopy.

Report on Leadership and Governance

EXECUTIVE SUMMARY
The report has been based on the diastases of cardiac arrest cause during gastroscopy.
Along with this, it has been undiscussed about the guidelines that need to be flowed by
medical partitioner. In addition to this, it has been depicting about the oral assessment tool that
can be used by nurse. Moreover, root cause analysis has been used in the project to analyse
about the problem faced by the 46 year old lady. Although PDSA has been provided to give
recommendation to the patient in order to meet the changes. The fives why's is included why
the patient suffered from Cardin arrest and why the patient was not treated with right medical
ways. Along with this why the nurse did not follow the sign chart and did communicate to
senior doctor. Moreover, for addressing this situation PDSA quality improvement cycle has
been followed in order to provide recommendation for changes.

Table of Contents
INTRODUCTION...........................................................................................................................4
MAIN BODY...................................................................................................................................4
Literature review.........................................................................................................................4
Discussions..................................................................................................................................5
Quality Improvement ..................................................................................................................7
Recommendation.........................................................................................................................7
CONCLUSION................................................................................................................................8
REFERENCES................................................................................................................................1
Appendix..........................................................................................................................................2
Appendix 1...................................................................................................................................2
Appendix 2...................................................................................................................................3

INTRODUCTION
The present report is based on the case study of 46 year old lady that have died due to
Result of complication of an air embolism which have occurred due to endoscopic procedures
that have undertaken to correct the complications of earlier surgeries. Although there were
act of negligence has been done by the nurse as there were no proper communication and
documentation of patient illness (Dolce and et.al,. (2018)). The state coroner stated that reason
for death was cardio - respiratory arrest related with an air embolism during gastroscopy.
Along with this, the study will discuss clinical practice guild line that need to be followed by
health practitioner in order to save patient. It will also decrepit about the oral assessment tool
which is used by medical practitioner so that proper flow of information is maintained. Along
with this, it will also discuss about oral assessment education that is required to be followed by
nurse. The report has define root cause analysis and PDSA plan.
MAIN BODY
Literature review
In the present case study the peer has reviewed articles not more than five years
using Cumulative index to nursing as well as medical literature. The key
learning points are clinical guidelines, nursing practitioner, oral assessment tool.
In addition to this, manual search of grey literature is conducted to gain the
information related to government guidelines and evidence based literature.
Moreover, in the first literature key phrases like clinical guidelines has been used
in which various articles has been adopted only 5 has been used which were
related to clinical practice guideline review.
Chosen article
 Randomised clinical trial: efficacy of strategies to provide oral hygiene
activities to nursing home residents with dementia who resist mouth care.
 MASCC/ISOO/ASCO clinical practice guideline
 Randomised clinical trial: efficacy of strategies to provide oral hygiene
activities to nursing home

A manual grey literature search also produced:
• Facility Clinical standards / policy and procedures
• National Safety and Quality Health Service (NSQHS) Standards
Theme 1: Clinical Practice Guideline Review
According to Finotto and et.al, (2020) clinical guideline is defined as systematically
developed statement that need to be followed by health practitioner so that health of patient is
maintained. Along with this, these guidelines are designed to support the decision-making
processes in patient care. POCT has developed standards for using evidence based procedure
which is related with management, implementation and operation as well as on going quality
evaluation of selected technology. It is beneficial for both patient and medical practitioner.
Moreover, Wharton and et.al,. (2020) has defined about National Pathology Accreditation
Advisory council (NPAAC) role OS to advice ministers on matter relating to authorization of
laboratories. It also responsible for development and maintaining the standards that helps in
defining the quality procedures for practice of pathology.
Theme 2: Vital signs
According to Krowchuk and et.al, (2019) has defined that it is the first step in helping an
aged person's health. It is use to identify whether an older person has any serious health issue.
Along with this, it is not similar to examination of vital care and it does not required longer time
as it is similar to general health assessment. As per the view of Sanz and et.al, (2020) it has
defined that examination of vital care can be conducted on the basis of regular basis or monthly
as well as when the need arises. Moreover, there are various tool that can be use by the doctor
such as thermometer in order to analyse body temperature. In case of older patient and younger
temperature should be checked every time so that in case of serious issues precaution is taken. In
addition to this in case of 46-year-old lady nurse has not checked the vital sign after surgery and
it did not even communicate. Thus, in medical this is the first action of health Practioner to check
the vital signs.
Theme 3: Vital sings check

As per the view of Yarom and et.al,. (2019) a nurse is required to undertake an vital
assessment in various sector of health care like hospitality, residential care or home of
patient. The nurse is required to make sure that it have proper knowledge, skills and confidence
in order to do the processes effectively. Although they need to work within their limit and
family of patient should be involved in mouth care. The role of the nurse is to monitor and
maintain the patient hygiene. Moreover, tools need to be appropriate and care should be
provided with person centred care.
Discussions
Clinical Practice Guideline Review
In the case study of 46 year old lady it has been found that it die due to cardiac arrest
which is related to air embolism. The guideline of clinical practice state that it is the duty o
nurse to identify the risk factor for the condition, diagnose criteria, finding the factor with or
without treatment as well as to analyse different treatment option. Along with this, health care
practitioner need to give proper care to patient. However, in the case of 46 year old ladies it
was diagnosed with the surgery of removing the large part of stomach as operation of obesity.
While surgery was going stapling device was not working so doctor require handing sew that
part. Although risk was identified by the doctor and treatment was provided to patient (Aoki,
and et.al., (2019)). However, the deceased faced symptoms like blood pressure and low oxygen
as well as fever. The nurse has not raised any of the concern regarding it to surgeon in the
morning. There was lack of communication between surgeon and nurse and due to that there
was delay in proving right treatment to deceased. This, is considered as wrongful practice in
nursing. Moreover, patient was given medication without even reviewing by the surgeon which
has resulted in unwell health of patient as well as after reviewing it for 6 hours it has been
found that patient was meeting all the criteria for medical emergency team. But still by the
nurse no call was made by them and no medical assessment as well as observation was
increased. Thus, hospital has not followed guideline set by POCT and RACGP standards for
point of care testing that management of clinic need to be improved in order to provide quality
services to patient ( IDolce and et.al,. (2018)). As well as to giver greater satisfaction to the
deceased like providing speedy diagnosis and treatment decision.
Oral Assessment tools

In the above case nurse has not maintained proper flow of communication and due to
that patient was not able to get proper treatment. Along with this, proper documentation of
record was not maintained like after surgery patient has symptom of cardiac arrest which was
not even mentioned in record to communicated to surgeon. Moreover, because of that patient
suffered from high fever and low oxygen rate. Without even checking medical condition the
medication was given to deceased which has lead in deteriorating condition. The MET Team was
also not called after continuous six hour observation and analysing that it was fulfilling the
criteria for emergency. Furthermore, the quality services was not provided by surgeon and it
was not even adequate (Coan, Wijesuriya & Seibert, (2019)). Although there was number of
stages where negligence was conducted by nurse and health care practician which has resulted
in bad health of deceased. Moreover., AHPRA has declared in the case that surgeon has lead in
serious inadequacies during the course and no communication between the nurse resulting
decreasing health of the deceased. Although during the case nurse has made an observation
chart and has given evidence regarding the emerge but doctor has not paid attention to it. In
addition to this, there was lack of communication between the nurse during the time of shift.
Oral Assessment Education for Nurses
The nurse need to identify the risk and find various ways to treat the patient. Along
with this, in the above case it has been found that surgeon has identified the risk but
medication was not proper and due to that patient health was devastated. The nurse has not
recorded the symptom properly and not communicated further to senior surgeon. Although poor
quality of treatment was provided to the patient by both nursing staff and surgeon and that
has lead in death of the patient (Warren and et.al.,(2019)). It was found that this failure to take
adequate observation of patient has lead in failure on the part of the hospital and nurse
involved in the treatment of the deceased. Moreover, the hospital need to teach their nurse
about taking care of patient effectively like writing the observation and give the details to
senior as well as to other shift nurse. That will help in giving quality services to the patient.
Quality Improvement
The PDSA cycle is known as continuous quality improvement cycle which is used to
give recommendation and suggestion to patient. Along with this, in the first stage of PDSA
all the stakeholders will be informed that will help in providing the role to staff management. In

the second stage one group of staff will administer medication and monitor the vital signs. In
the last stage all the data has been collected and recommendation is provided on that basis.
Recommendation
 It is to be suggested to hospital that it should give proper training to the nursing staff so
that it can give quality services to the patient. Although then management need to be
structured that will result in reducing the failure in the case. Along with this, it will help
in providing clear instruction to the staff so that every one is aware about their job and
duties that need to be followed. Moreover, the proper training will allow in working
more efficiently and it will help in giving proper care (Ek and et.al., (2018)). Although
proper flow of communication need to be managed between staff will reduce the failure
of case.
 It is to be recommended to hospital for changing the practice is that it can adopt for has
electronic medication management that will help in improving the quality of work.
Along with this, it includes providing support for the doctors, nurse, administration of
medicines and pharmacists. It also helps in preventing medical errors by flagging
potential drug interaction or adverse reactions (Jablonski and et.al., (2018)). Along with
this, it also helps in coordinating with patient as EHR helps in updating patient data
and present that information in clinical group and the data can be access easily.
CONCLUSION
From the above report it has been concluded that leadership is very much important in
medical line in order to manage the functions. Along with this, above study was presented on
case of cardiac arrest due to air embolism during gastroscopy. The patient in case died due to
not getting the proper treatment by nurse and surgeon. The study has done literature review on
the guideline of medical line that need to be followed by health practitioner. In Australia there
has been authority like AHPRA that make polices that need to be followed by heath staff.
Although in the above case it has been found that nurse has not followed this guideline like it
has not recorded about the illness of patient and not communicated about the health
condition. In this case surgeon has without even checking the condition has given medication
to patient. The study has also undiscussed about oral assessment that need to be followed by

nurse and tools which can be used to treat people. Lastly, it has given recommendation to the
hospital in order to improve their service. The report has define root cause analysis and
PDSA plan.

REFERENCES
Books and journals
Aoki, T. and et.al., (2019). Inter-rater reliability of the Oral Assessment Guide for oral cancer
patients between nurses and dental hygienists: the difficulties in objectively assessing
oral health. Supportive Care in Cancer. 27(5). 1673-1677.
Coan, L. L., Wijesuriya, U. A., & Seibert, S. A. (2019). Collaboration of Dental hygiene and
nursing students on hospital units: an Interprofessional education experience. Journal of
Dental Education. 83(6). 654-662.
Dolce, M. C. and et.al,. (2018). Integrating oral health curricula into nurse practitioner graduate
programs: results of a US survey. Journal of the American Association of Nurse
Practitioners. 30(11). 638-647.
Ek, K. and et.al., (2018). Healthcare providers’ experiences of assessing and performing oral
care in older adults. International journal of older people nursing. 13(2). e12189.
Finotto, S. and et.al, (2020). Linguistic-cultural validation of the oral health assessment tool
(OHAT) for the Italian context. BMC nursing. 19(1). 1-9.
Jablonski, R. A. and et.al., (2018). Randomised clinical trial: efficacy of strategies to provide
oral hygiene activities to nursing home residents with dementia who resist mouth
care. Gerodontology. 35(4). 365-375.
Krowchuk and et.al, (2019). Clinical practice guideline for the management of infantile
hemangiomas. Pediatrics. 143(1).
Petrovski, M. and et.al., (2019). Oral health education of staff in long-term care
institutions. Balkan Journal of Dental Medicine. 23(2). 63-67.
Sanz, M. and et.al, (2020). Treatment of stage I–III periodontitis—The EFP S3 level clinical
practice guideline. Journal of Clinical Periodontology. 47. 4-60.
Warren, C. and et.al.,(2019). A nurse-driven oral care protocol to reduce hospital-acquired
pneumonia. AJN The American Journal of Nursing. 119(2). 44-51.
Wharton, S. and et.al,. (2020). Obesity in adults: a clinical practice guideline. Cmaj. 192(31).
E875-E891.
Yarom, N. and et.al,. (2019). Medication-related osteonecrosis of the jaw:
MASCC/ISOO/ASCO clinical practice guideline. Journal of Clinical Oncology. 37(25).
2270-2290.
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Appendix
Appendix 1
Example of root cause analysis
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Appendix 2
Example of the ISOBAR format
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