401021 Nursing Case Study: Patient A Incident and Analysis

This document presents a detailed analysis of a nursing case study centered on the incident involving Patient A. The assignment begins with a summary of the case, highlighting the patient's symptoms, treatment, and ultimate demise, attributed to septicaemia. It then delves into contributory factors, identifying multiple professional errors, including the Visiting Medical Officer's (VMO) inconsistent diagnosis, the hospital's inadequate patient care, and communication breakdowns. Specific issues include the VMO's unavailability, lack of standard procedures, and clinical handover deficiencies. The analysis references national standards and guidelines to underscore these errors. Finally, the assignment discusses implications for future practice, emphasizing the importance of adhering to safety and quality standards, improving clinical handover processes, enhancing communication, and ensuring access to quality diagnostic and care services to prevent similar incidents. The document concludes with a reference list supporting the analysis.

Assessment
Criteria 1. Case Summary: Summarizes the case and
presenting professional practice issues.
Answer:
The case is related to patient “A” who was 81 years old and had a complaint of
breathlessness for two nights while lying flat. The patient was given a number of
medications ranging from Oral laxis to Digoxin and Valium. The case indicated that
patient was returning again and again with his problems such as diarrhoea, tenderness in
abdomen, weakness, food refusal. The patient was under Visiting Medical Officer
(VMO). The VMO made different types of diagnosis and medications for this patient. For
example, VMO diagnosed patient A with depression and anxiety. One of the registered
nurse of hospital provided the useful insights related to the major issues involved in
patient’s A case. The RN indicated that condition of the patient was the matter of
concern. RN found that there were issues on the end of hospital as the hospital was not
equipped properly so that the high quality patient care can be provided to patients. RN
also indicated that the treating doctor of patient A had gone away and was unable to be
contacted. The RN indicated that the doctor was not available to see patient A and
therefore, she was intended to be seen by a locum who arrives only on Friday Evenings.
By the time locum arrived in hospital patient A was critically unwell. The emergency
doctor was also called seeing the critical position of the patient. The patient was severely
dehydrated and it was highly complex to transfer her to another hospital as he/she was
critically ill. Patient A died when she was being evacuated by the Air Evacuation Team.
The primary cause that led to death of patient A was stated as septicaemia. The overall

case indicates that there are number of professional issues in the case that led to death of
patient. This case will discuss these issues in detail.
Criteria 2. Contributory factors: Identify relevant
professional errors that potentially contributed to
the incident happening?
Answer
There are number professional errors that contributed in the death of Patient A. Firstly,
the VMO was not able to diagnose the health condition of Patient A. VMO was using the
trail and hit method for diagnosing the healthy condition of her. This led to deterioration
of health condition of the patient. The VMO might have conducted wrong diagnostic test
on patient A that led to consistent deterioration of health condition of her. According to
National Safety and Healthy Quality Standards, the diagnosis of patient’s health
condition forms the foundation of overall treatment and cure of patient. The VMO who
was looking after patient had suddenly become unreachable.
Second major cause of patient A’s death include the inefficiency of hospital to provide a
high standard patient care to its position. This can be evident from the case that hospital
did not have any standard procedures regarding the process such as patient handover.
VMO was suddenly out of the scene and patient was dependent on a locum. A locum is a
person who works temporarily in a particular position. The locum was new to patient’s
case and could not have been efficient in pursuing the patient’s case as she was already
very ill (Medcas, 2018). Hospital could have provided the documented roles and
responsibilities to locum regarding the patient’s case. This would have helped the locum
in understanding the case of patient A along with the determining the future course of

actions. The guidelines of National Safety and Quality Health Standards also indicate that
the locums assigned for patient should have necessary training, information so as to fulfil
their quality and safety rules.
During the course of treatment Patient A, she also contracted UTI (Urinary Tract
Infection). This may be because hospital did not have quality strategies and systems that
can present the infections among patients. Further, there was a major defect in the clinical
handover process of hospital. The patient was transferred to another doctor without any
documentation. A clinical transfer can be defined as the process of transferring the
professional accountability and responsibility associated with a patient to another
professional group on permanent or temporary basis (Barratt, Harrison, Rowan, & Raine,
2012). Patient A should have been seen from a same doctor from start to end of
procedure. Even if the case was transferred to other doctor the process should have been
documented. The clinical handover should have also provided a list of reasons and
medicines for the patient.
The case study also indicates that there were communication issues in the hospital that
prevented the process of information flow from one person to another who were involved
in the care of patient A. Clinical communication is one of the important aspects of a
quality health care. Clinical communication can be defined as the exchange of
information that takes place among the clinicians while treating a patient. This form
communication should preferable be formal that conforms to a pre-defined structure. The
communication issue in hospital is evident from the fact that Ms Jones who was the
Clinical Nurse Manager of hospital was not provided detailed information about the
patient but she signed the medication for the patient. There are no evidences from the

case that indicate that doctors involved in case of patient A communicated with each
other on the health condition of patient. The managers and leaders of hospital should
focuses on improving the communication in health setting so as ensure that none of the
important information related to the patient is missed (ACHS, 2018). For example, the
hospital could have communicated the strategies that can help in preventing the infections
such as UTI blood infection that was stated as the cause of death of patient A (Australian
Commission on Safety and Quality in Health Care, 2017).
Criteria 3. Implications for future practice:
Discussion that includes how your practice might
change and develop as a result of this learning.
What professional behaviours may have made a
difference in this situation?
Answer
As a result of learning obtained from this particular case, my practice and will changes
and develops in future. In this context, I will focus on the ten standards that are given by
National Safety and Quality Health Service Standards. According to these standards, I
will focus on describing the strategies and systems that can ensure that clinicians safely
prescribe the medicine to patients. A standard procedure will help in ensuring that
appropriate medicines are prescribed to patients. Further I will also focus on changing the
process of clinical handover in the organization. The accountabilities and responsibilities
of both the clinicians involved in the process of patient handover will be clearly defined
so that the new doctors knows exactly that how the patient has to be handled in future. I
will also focus on improving the quality of communication in hospital so that there is a
better exchange of information among the health care professionals. Finally, I will also

focus on ensuring that hospital has some of the best diagnostic and care services so that
patient does not need to be transferred in other hospital. There are various professional
behaviours that could have made a difference in the situation. Firstly, the VMO could
have informed the hospital management about his absence. In addition to giving prior
information, VMO should have also focused on assigning a new doctor for patient A
(Nursing and Midwifery Board of Australia, 2018). VMO could have adopted a
professional way of clinical handover by clearly defining the roles, responsibilities and
accountabilities of the new doctor (Nursing and Midwifery Council, 2019).
Reference list
ACHS. (2018). Report of the ACHS National Safety and Quality Health Service (NSQHS)
Standards Survey . From Parliament.act.gov.au:
https://www.parliament.act.gov.au/__data/assets/pdf_file/0016/1240711/
Australian-Council-on-Healthcare-Standard-National-Safety-and-Quality-Health-
Service-Standards-Survey-Report.PDF
Australian Commission on Safety and Quality in Health Care. (2017 йил November).
National Safety and quality Health services standards. From
Safetyandquality.gov.au:
https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-
and-Quality-Health-Service-Standards-second-edition.pdf
Barratt, H., Harrison, D. A., Rowan, K. M., & Raine, R. (2012). Effect of non-clinical
inter-hospital critical care unit to unit transfer of critically ill patients: a
propensity-matched cohort analysis. Critical Care, 16.

Medcas. (2018). Locum Doctors. From Medcas.com: https://www.medacs.com/locum-
doctor-jobs
Nursing and Midwifery Board of Australia. (2018). Professional standards. From
Nursingmidwiferyboard.gov.au:
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Professional-standards.aspx
Nursing and Midwifery Council. (2019). Becoming a nurse, midwife or nursing
associate. From Nmc.org.uk: https://www.nmc.org.uk/education/becoming-a-
nurse-midwife-nursing-associate/