Clinical Incident Report: Factors, Implications for Future Practice

This report presents an analysis of a clinical incident involving an 81-year-old female patient admitted to a clinic with breathing difficulties. The report details the patient's deteriorating condition, including the lack of timely actions, clinical negligence, and systematic attention, ultimately leading to the patient's death. The analysis identifies contributory factors such as ineffective communication, failure to adhere to nursing standards, and delays in providing necessary diagnostic tests and treatments. The report highlights the importance of critical thinking, responsive practice, and comprehensive care in healthcare. The implications for future practice emphasize the need for registered nurses to prioritize patient safety, improve clinical governance, and ensure immediate action in response to patient deterioration. The report underscores the significance of reflection, communication, and proper documentation to prevent clinical errors and enhance the quality of care. Recommendations include improved communication, documentation, and adherence to safety standards to mitigate risks and improve patient outcomes.

Clinical incidents

TABLE OF CONTENTS
CASE SUMMARY .........................................................................................................................1
CONTRIBUTORY FACTORS.......................................................................................................1
IMPLICATIONS FOR THE FUTURE PRACTICE ......................................................................3
REFERENCES ...............................................................................................................................5

CASE SUMMARY
The professional practice issues in health care sector includes issues such as
accountability, responsiveness, team work, ethical considerations, duty of care and patient safety.
For the safety and improved health outcome of the patient is necessary that health care service
providers must pay attention to the physiological changes occurring and quick response and
attention must be given to them by considering their severity and significance (Magalhães &
et.al., 2019). The lack of timely actions and negligence can enhance the risk factor for the
patient.
An 81-year-old female, named A was admitted to clinic on account of breathing shortness
and breathlessness from the last two days. On diagnosis patient was found to have fine creps at
lungs and high venous pressure. Despite initial medication her condition did not improve and
accompanied by diarrhoea and abdomen tenderness. The patient refused to take food or liquid
and complained of high level of pain. With the passing time the condition of patient was
deteriorating with low blood pressure, increasing respiratory rate and skin disintegration. The
patient became was feeling very dizzy, anxious and diagnosed with urinary infection.
Along with the regular abdominal pain patient A was suffering from severe weakness
making it hard to mobilize her. Her skin became pale, grey, cold, and she regularly complained
of back pain. When the condition of patient became highly critical only then attempts were made
to shift her to rural hospital but due to septicaemia she died whilst assessed by air evacuation
team. It can be concluded form the clinical incident that the lack of improper care services,
delay, clinical negligence and systematic attention to patients leads to the death of patient.
CONTRIBUTORY FACTORS
Professional errors results from the ineffective implementation of the code of conducts
and practices recommended for the registered nurses and other health care professionals. In the
given case study of patient A there has been several factors which lead to the errors and clinical
negligence. The patient could have been saved if these errors were taken into consideration and
appropriate action would have been taken into the account. According to Mahmoud, (2016) the
nurses must pay attention to all the vital symptoms of the patient. They must understand the
needs of their patients and work in the partnership with the patients. This is one of the most
important principle of national health and safety quality standards.
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However, when patient A was admitted to hospital on 5 January no significant
communication was made and only medication were given to her. Even where no improvement
signs were shown by the medication no satisfactory action was taken on next day. The necessary
diagnostic tests were planned after 2 days which worsen the symptoms and condition of patient.
This can be considered as significant professional error related to clinical negligence and
ineffective patient partnership.
On 10 January when patient had abnormal readings of respiratory rate no satisfactory
actions was taken. In such situation it was expected that registered nurses must fool their practice
standard of critical thinking and responsive practice. However, the pain level, skin changes,
abdominal tenderness and other vital symptoms were not taken seriously. When she was
diagnosed with UTI then suitable measures must be taken to prevent and control the infection.
As per the view of Calero, Gomila & Fullana, (2019) comprehensive care and recognition of
acute deteriorating health condition of patient is major safety standard. However, when patient
was regularly complaining of the symptoms and it was required to mobilize her the need was
ignored.
In the absence of treating doctor no alternative or emergency care was provided to her. It
enhances the infection risk and safety threat for the patient A. When the critical situation of
patient was informed to respondent then she refused to take suitable actions instead she insisted
on waiting for locum who was supposed to arrive after few hours. It contributed in deteriorating
the patient health. Dello Stritto & Landrum, (2016) stated that nurses must work in the
collaboration with other workers so that patient safety can be assured. However, when enrolled
nurse refused to review the patient respondent review the patient, but she did not make any
documentation. It initiate the higher possibilities of clinical error due to medication or
negligence. On the arrival of locum when it was required to give emergency assistance to patient
A then also instead of providing quick services emergency doctor arrived after one hour.
The continuous delay in providing treatment to patient and neglecting the need to provide
necessary treatment on time made condition of patient highly critical. It has been also observed
that RN lacks the ability to make critical analysis and decision. Thus, they decided to refer
patient only when it become impossible for them to mobilize patient. It has been also observed
that when the locum arrived only dehydration medication was given without paying attention to
the possible infection risks and other complications. It leads to the death of patient A due to
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septicaemia which is higher prevalence in UTI, abdominal infection and can be expected by
symptoms of nausea, redness on skin and reduce volume of urine.
IMPLICATIONS FOR THE FUTURE PRACTICE
For the future practice nurses must understand that their first priority must be the safety
and well-being of the patient. They must emphasis their role in partnership with patient,
increased clinical governance, prevention, medication safety and comprehensive care. The
registered nurses must assure that on the basis of their improved clinical governance and
decision-making they must minimize the health complications for their patients (Dello Stritto &
Landrum, 2016). Registered nurses must also assure that if clinical settings does not have
necessary equipments or the care facilities then patient must be immediately refereed to other
settings so that their health outcomes can be prevented from deterioration or the risk factors.
If nurses do not consider safety and nursing practice standards then it can affect the
quality of services provided by them and safety of patient can be put at higher risk. The clinical
negligence and professional errors arising due to lack of these practice principles is not only
harmful for the safety of patient but also has adverse impact upon professional outcomes of
nurses as well. Reflection is one of the important part of the learning process (Cediel & et.al.,
2019). Thus, if nurses will not incorporate safety standards and regulations then they may not
justify their role as registered nurse or responsible health care professional. Usually nurses does
not communicate the deteriorating health if the treatment providing doctor is not available.
However, such events must be reported immediately without considering them less significant.
Nurses can take variety of steps to address the challenges and complicated events which
may occur in their clinical settings. In order to improve the service quality nurses must
communicate with patient as well as other co-workers. During transition of nurses or the shifts
the communication and proper documentation must be performed accurately so that incharge of
patient can be given to other professionals safely and accurately. Nurses must also understand
that in any circumstances they must not put patient at risk. Thus, with regular clinical monitoring
as soon as any complications are observed immediate actions must be taken (Campino & et.al.,
2018). If the treating doctor is not present then this must be reported to other team members and
quick alternative must be taken. This approach will assist in prevention and quick response to
acute deterioration in the patient's health condition. It is also recommended that nurses must
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inform all the possible health risk to patient or carer so that needs of the patient can be
understood with more clarity.
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REFERENCES
Books and Journals
Calero, M. Á. R., Gomila, C. J. V., & Fullana, P. S. (2019). Advanced practice nurses and
evidence-based practice. An opportunity for change. Enfermería Clínica (English
Edition). 29(2). 119-124.
Campino, A. & et.al., (2018). Intravenous medicine preparation technique training programme
for nurses in clinical areas. Eur J Hosp Pharm. 25(6). 298-300.
Cediel, G. & et.al., (2019). Clinical Acceptance of the Universal Definition of Myocardial
Infarction. Revista Española de Cardiología (English Edition). 72(4). 353-355.
Dello Stritto, R. A., & Landrum, P. A. (2016). Patient Safety: An Interprofessional Education
Approach.
Magalhães, A. M. M. D. & et.al., (2019). Medication administration–nursing workload and
patient safety in clinical wards. Revista brasileira de enfermagem. 72(1). 183-189.
Mahmoud, M. A. (2016). Evaluation of Medication Safety Challenges and Prescribing Errors
Among Hospitalized Patients in a Saudi Arabian Private Hospital (Doctoral dissertation,
Universiti Sains Malaysia).
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