Risk Management and Health Safety

Running Head: case study
Risk management and Health Safety
Name of the Student
Name of the University
Authors Note

Risk management and Health Safety
1
Introduction
Nurses and the healthcare professionals have vital role in communicating with the
patient’s family and the other health professionals. National Safety and Quality Health
Service Standards have established different facilities for improving the quality of
communication and widening the range. The communication is important in reporting
patient’s deterioration and in connecting a health professional to other for discussing the
better interventions. Communication and proper documentations are very much related to
each other in the field healthcare (Redley, Botti, Wood & Bucknall, 2017). Standard six of
NSQHS is focused on transferring the information regarding critical patients and proper
identification of the patient care in terms of person to person communication. Evidence of a
patient’s treatment will be collected from the cues of inter-professional communications.
Significance of usage of the early warning tools and the escalation systems will help in
indicating different causes of patient’s deterioration. Different other protocols are present in
the sector of healthcare to investigate the reason of a patient’s death. The Coroners Act 2009
states that the inquests determine the causes of death with analyzing the underlying factors
and different aspects related to the death of a person. This report is based on different
communication gaps and missed opportunities in communication with the references of the
ineffectiveness of the nurses and doctors to control deteriorating signs of a pediatric patient.
This report will discuss about the limitations and will propose some recommendations for the
case study of Troy Almond, who died due to lack of efficiencies of the healthcare
professionals.

Risk management and Health Safety
2
Discussion
Missed opportunities and areas of gaps in the RN’s electronic communication
The case study shows that Troy Almond was admitted to the hospital (Shoalhaven
District Memorial Hospital) by Ms Macklin, registered Nurse of the hospital. When the boy
admitted (10:15am on 21 March 2016) to the hospital, RN Pamela Mason examined him and
all the vital signs were recorded by her in the electronic medical records (Coroners Court of
New South Wales, 2018). She assessed that the Capillary refill rate is brisk in him but she did
not measure his blood pressure which is very important vital sign. After that she allocated
troy in Triage category 3 and transferred him to the Pediatric department. She completed the
triage assessment and handed over Troy to the present RN in Charge and to the doctor of the
pediatric bay, Dr Babak Tajvid as shift of the paediatric RN had not commenced. The
allocated nurse of that department was RN Shaun Avis and he joined between 10.50am and
11.00am. He recorded his observations in the EMR by using iView. RN Avis reported that
the doctor recorded the vital signs and assessed the boy at the same time when was assessing
the patient. The medication chart gave the evidence that the doctor should have assessed the
patient at 11.30am when he gave the doses of Panadol and Nurofen. At 12.30 pm, RN Avis
noticed that he had rashes. However the plan of insertion of cannula was intended at 1.06 pm.
During the investigation the expert Professor Raftos showed that the heart rate of the patient
must be noted down and the allocated health professional should opt for blood tests (Coroners
Court of New South Wales, 2018). However the RN and the doctor emphasized on the
appearance of the patient. During the investigation, the RN recalled that the rashes were
blanching, which was not mentioned in the documentation. The inquest shows that a lots of
confusion were present in the time of discharge of Troy. Dr. Tajvidi did not assessed Troy
and referred any blood tests for him before discharging him. There were lots of confusion in
the evidence given as per the RNs and the doctor about Troy’s clinical appearance. Ms