NUR3201: Registered Nurse Accountability in the Troy Almond Case Study

This report critically examines the case study of Troy Daniel Almond, who tragically died due to a streptococcal infection. It focuses on the roles and responsibilities of registered nurses in providing care, particularly concerning electronic communication and accountability within the Shoalhaven District Memorial Hospital. The report analyzes missed opportunities in patient record-keeping and the failure to utilize tools like the SPOC and Between the Flags approach. It highlights the significance of communication between healthcare professionals, the importance of early warning tools in predicting patient deterioration, and the application of Ryan's Rule. The report also discusses strategies for mitigating risks related to communication and accountability, emphasizing the need for staff training and adherence to established policies. The analysis underscores the critical impact of effective communication, accurate documentation, and the use of early warning systems on patient outcomes and the prevention of medical errors.

Name of student:
Registration number:
Unit title:
Unit Code:
Assignment title:
Name of supervisor:
Date due:

Introduction
Adherence to laid down procedures is very critical in the provision of care. This paper
analyzes the case study of Troy Daniel Almond, who was born in the year 2004 October. The
boy fell sick on21st March 2016 and was presented in the emergency department at the
Shoalhaven District Memorial Hospital on the same day. He was recorded as being lethargic,
pale and febrile, and restless. His vital signs, such as blood pressure, temperature, and respiratory
rate, were also unusual. This paper, therefore, examines the role of nurses and their
accountability in electronic communication about Troy's case. The paper also discusses the
importance of early warning tools, such as the ones used in NSW hospitals. Furthermore, the
paper discusses the application of the Ryans Rule can be applied in practice by Registered
Nurses. Risk mitigation strategies that could be applied to avoid missed opportunities for
communication and accountability are also discussed in this article.
Missed opportunities and gaps
Entering of patient records is very critical in offering care to patients. Registered nurses
are expected to enter the patients' data in records either electronically or manually in situations
where electronic record-keeping is not available ( Semper et al., 2016). At every point where the
information about a patient, such as vital signs, the nurses are expected to record the information
because it is vital for communication between the various medical professionals involved in the
care of the patient. The records can be useful in assessing the progress of the patient. RNs are
expected to use electronic communication to relay accurate and precise data that is stored for the
future. Registered nurses are held accountable for failure to follow the established procedures of
assessing patients and recording data such as non-adherence to the policy on Recognition and
Management of Patients who are clinically deteriorating (Winter et al., 2018). The law also

requires proper and accurate communication by the registered nurses since the information
communicated by them is relied upon by doctors in making decisions (Wagner, 2018). These
decisions could have a significant impact on the patient, and hence RNs must communicate
essential data. The registered nurses should not ignore any of the policies or facilities available in
the facility that could improve communication between various professionals working in the
hospital. One of the missed opportunities is the failure by the nurses in the emergency
department to use the SPOC when Troy was presented to the hospital. This is despite the
policies requiring that nurses use the SPOC for all infants between 1 and four years. The use of
the chart is critical in establishing a set of parameters used in recognizing a patient if their
condition might become worse based on the reading of the charts on the patients' vital signs
(Ridelberg, Roback & Nilsen, 2018). This, therefore, guides the nurses on the appropriate
decision that should be taken based on the readings on the chart. This could, therefore, have
helped in diagnosing the patient with a bacteria infection and not the virus as the doctors had
assumed earlier.
Relevance of communication and accountability of RNs
Communication via writing is also critical for RNs as well as doctors. Observations made
by RNs while examining the patient should all be recorded either manually or electronically.
This is because this data could be required for clinical review or legally when investigating a
case like in this scenario (Thomas-Jones et al., 2018). Dr. Tajvidi examined Troy and made the
impression that Troy was suffering from viral infections, but he did not record his observations
or insights. He later admitted while presenting oral evidence that he made a mistake, and he
should have recorded that the patient had either viral or bacterial illness.

Communication is also very critical for RNs since it improves decision making. Effective
communication between RNs and Physicians and RNs themselves can improve decision making
because it contributes to the exchanging of ideas on a particular situation or scenario (Toloo et
al., 2018). Once the experts can communicate, they exchange ideas and come up with a better
decision compared to if there is no effective communication. In this case, for example, If Avis
had communicated his observation of rashes to another RN or the doctor, they could have helped
in determining whether the rash was non-blanching or blanching. This would, therefore, have led
to making the right decision when treating Troy of the infections he was suffering from.
Rationale of Early Warning Tools and documentation policies
Early warning tools and recording is very critical for pediatric patients. Studies have
proven that the use of the pediatric track and trigger tools(PTTT) for predicting adverse
outcomes for hospitalized children and other patients has been very effective (Chapman et al.,
2016). One of the advantages of the tools is that they have high diagnostic accuracy. For
example, if the doctor and the nurses have used the Between the Flags approach, they could have
seen that Troy's heart rate was in the red zone by the time he was admitted to the hospital. The
tool would also have helped to notice that the child's temperatures and heart rate were in the
yellow zone just before discharge. This could probably have convinced the doctor that Troy
needed further examination, and he should not have been discharged that early. Both RN Mason
and RN Avis should have used the BTF approach during triage, and during ongoing
observations, since it could have resulted in a different outcome for the patient.
Research has also established that early warning tools have contributed to a decrease in
the mortality rate (Downey et al., 2017). This is because they assist RNs in identify early signs of
severe sickness or deterioration of the patients' condition. Hence, corrective measures are taken

in advance. Some of the interventions undertaken to assist patients once vital signs are very high
include the urgent calls of resuscitation teams, emergency transfer of patients to high dependency
units, and pediatric ICU. Compared to the manual observation of patients, electronic recording of
a patient's vital signs increases accuracy to 98.5% compared to 85.6 % when electronic
surveillance is not used (Dean et al., 2017). A systematic study conducted among RNs also
indicates that the use of an electronic recording of patient vital signs and the early warning tools
offered safety benefits since it reduced human error while providing instant visibility of recorded
data to all members of the clinical team (Lambert et al., 2017).
Application of Ryan`s Rule by RN`s
The Ryan rule introduced changes that gave parents a say in advocating for the health of
their child. The rule states that a patient or their caregiver should talk to a nurse or doctor about
their concerns. If the person feels that the response is not adequate, they should proceed to step
two which involves talking to the doctor or nurse in charge of the shift and if it fails the carer
should call 13 HEALTH and request a Ryan's Rule Clinical Review (Dwyer et al., 2020). This
rule can be applied to RNs taking care of a patient who is critically ill, and their condition is not
improving. If the parent of a child or any other patient feels that the Registered nurse is not
acting in the best interest of their patient and is not paying attention to their concern, they can
instigate the steps listed above so that the issue can be escalated. For the case of Troy, his
mother, Kim Macklin, should have raised the concerns that her son had not undergone blood
tests to establish the cause of his severe illness. His concerns would have been valid since the
vital signs of Troy were very high and could have indicated that he required blood tests to
establish the cause of the disease (McLellan et al., 2017). Had Troy's mother used Ryan's rule,

there is a possibility that the life of the boy could have been saved since it could have persuaded
Dr. Tajvidi to conduct blood tests, which could have led to the correct diagnosis.
Synopsis of strategies
To mitigate the risk of missed opportunities for communication and accountability, it is
critical for registered nurses to get further training on the use of the early warning tools used in
the hospital (Zittel et al., 2016). Regular training of staff is critical since it enables the RNs and
the Doctors to master the use of the equipment so that they can be used accurately to prevent
deaths and adverse effects of the disease. In the case of Troy, it is indicated that the hospital
ceased training of staff on the use of the system by the time RN Avis joined the hospital. This
means that he was never trained on the use of BTF and hence preferred using iView only
because he found it easy to use. The staff at the hospital also need extra training to improve their
communication, which is very vital when offering care, especially in the emergency department
(Puthumana et al., 2017).
To mitigate the risk of accountability, the hospital management needs to have tools to
monitor the healthcare staff to ensure that they are compliment with the systems and policies put
in place regarding communication and recording of patient data (Bonde Bossen & Danholt,
2018). Failure to adhere to the procedures and policies should lead to a strict disciplinary action,
which will encourage compliance.
Conclusion
Communication is very vital in healthcare since it ensures proper flow and exchange of
information, which is very helpful in offering high-quality care. It is, therefore, essential for there
to be appropriate communication between the RNs and the doctors to improve decision making,
which could lead to the improvement of patient outcomes. Recording patient information

electronically and use of early warning tools is very helpful in improving patient outcomes and
in reducing mortalities. Parents or carers who feel that their patient is not receiving appropriate
care should follow Ryans rule to ensure that their concerns are addressed. Hospitals and other
care providers also need to provide sufficient training to new staff members on the use of various
tools and equipment used in the facilities to avoid unnecessary errors that could affect the patient
adversely.
References
Bonde, M., Bossen, C., & Danholt, P. (2018). Translating value‐based health care: an experiment into
healthcare governance and dialogical accountability. Sociology of health & illness, 40(7), 1113-
1126.
Chapman, S. M., Wray, J., Oulton, K., & Peters, M. J. (2016). A systematic review of paediatric track
and trigger systems for hospitalized children. Resuscitation, 109, 87-109.
Dean, N. P., Fenix, J. B., Spaeder, M., & Levin, A. (2017). Evaluation of a pediatric early warning score
across different subspecialty patients. Pediatric critical care medicine, 18(7), 655-660.

Downey, C. L., Tahir, W., Randell, R., Brown, J. M., & Jayne, D. G. (2017). Strengths and limitations
of early warning scores: a systematic review and narrative synthesis. International journal of
nursing studies, 76, 106-119.
Dwyer, T. A., Flenady, T., Kahl, J., & Quinney, L. (2020). Evaluation of a patient and family activated
escalation system: Ryan's Rule. Australian Critical Care, 33(1), 39-46.
Lambert, V., Matthews, A., MacDonell, R., & Fitzsimons, J. (2017). Paediatric early warning systems
for detecting and responding to clinical deterioration in children: a systematic review. BMJ open,
7(3), e014497.
McLellan, M. C., Gauvreau, K., & Connor, J. A. (2017). Validation of the children's hospital early
warning system for critical deterioration recognition. Journal of pediatric nursing, 32, 52-58.
Puthumana, J., Fong, A., Blumenthal, J., & Ratwani, R. (2017). Making Patient Safety Event Data
Actionable. Journal Of Patient Safety, 1. doi: 10.1097/pts.0000000000000400
Ridelberg, M., Roback, K., & Nilsen, P. (2018). How Can Safer Care Be Achieved? Patient Safety
Officersʼ Perceptions of Factors Influencing Patient Safety in Sweden. Journal Of Patient Safety,
1. doi: 10.1097/pts.0000000000000262
Semper, J., Halvorson, B., Hersh, M., Torres, C., & Lillington, L. (2016). Clinical nurse specialists
guide staff nurses to promote practice accountability through peer review. Clinical Nurse
Specialist, 30(1), 19-27.
Thomas-Jones, E., Lloyd, A., Roland, D., Sefton, G., Tume, L., Hood, K., ... & Lacy, D. (2018). A
prospective, mixed-methods, before and after study to identify the evidence base for the core
components of an effective Paediatric Early Warning System and the development of an
implementation package containing those core recommendations for use in the UK: Paediatric

early warning system–utilisation and mortality avoidance–the PUMA study protocol. BMC
pediatrics, 18(1), 244.
Toloo, G. S., Aitken, P., Crilly, J., & FitzGerald, G. (2016). Agreement between triage category and
patient's perception of priority in emergency departments. Scandinavian journal of trauma,
resuscitation and emergency medicine, 24(1), 126.
Wagner, E. A. (2018). Improving patient care outcomes through better delegation-communication
between nurses and assistive personnel. Journal of nursing care quality, 33(2), 187-193.
Winter, M. C., Kubis, S., & Bonafide, C. P. (2018). Beyond Reporting Early Warning Score Sensitivity:
The Temporal Relationship and Clinical Relevance of" True Positive" Alerts That Precede
Critical Deterioration. Journal of hospital medicine, E1-E6.
Zittel, B., Moss, E., O'Sullivan, A., & Siek, T. (2016). Registered nurses as professionals:
Accountability for education and practice. OJIN: The Online Journal of Issues in Nursing, 21(3).