NUR3201 Quality, Safety, Risk: Analyzing the Roy Jacobs Case Study

This essay delves into the Roy Jacobs case, a tragic instance of healthcare mismanagement marked by critical failures in communication, accountability, and recognition of clinical deterioration. The analysis underscores the importance of therapeutic communication and a robust accountability culture within healthcare organizations. It highlights how the failure to recognize and respond to clinical deterioration, coupled with non-compliance with early warning systems, contributed to the patient's unexpected death. The essay further explores the factors contributing to unrecognized clinical deterioration, such as inadequate patient monitoring, lack of training, and misdiagnosis, emphasizing the need for improved monitoring tools, staff expertise, and adherence to nursing codes of practice. The essay concludes by advocating for enhanced patient monitoring in general wards to facilitate timely diagnoses and interventions, ultimately aiming to reduce mortality risks and improve patient outcomes.

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Contents
Introduction.................................................................................................................................................2
Background of the case...............................................................................................................................2
Analysis and strategies................................................................................................................................3
Conclusion...................................................................................................................................................5
References...................................................................................................................................................6

Introduction
Communication in healthcare services is considered to be one of the important pillars for
providing effective health care to the patient (Faizipour & Perreira, 2013). The communication
among the nurses, doctors and other healthcare staff is vital to understand the logic behind
planning, implementation, and evaluation of the intervention been given (Patrick, 2017).
Communication is a root through which each medical staff involved in the case gets aware about
the latest update on the patient’s wellness or clinical deterioration. Once the patient is admitted in
the hospital, it is the responsibility of the healthcare provider to provide the best standard care
regimen, irrespective of any other reason involved in the case (Kalyandooj et al., 2017). In this
essay, Roy Jacob’s case will be analyzed wherein his sudden death caused a severe violation of
the care practice standards and practices. There was a significant lack of communication, lack of
accountability and extreme case of negligence that violates the nursing codes of practices.
The essay will critically analyze one of the statements “Failure to recognize and respond
to clinical deterioration and non-compliance with early warning and response tools is a
recognized issue across the health sector, public and private” and provide a detailed insight into
the statement highlight the latest evidence available to support the argument.
Background of the case
Jacob Roy is a 48-year-old man belonging to an aboriginal community who died
unexpectedly on 31st August 2017 at Cherbourg Hospital. As reported by the family members,
Roy was quite a happy man with a big family and during his death, he was staying in Brisbane to
spend time with his grandchildren within the community. He recently visited a funeral and was
intoxicated with alcohol that leads to falling and admitted to Cherbourg hospital. During his final
presentation, he was given with treatment for pneumonia, and despite certain resuscitation
efforts, he was found to be unresponsive and later found dead. With a sudden death of the patient
with unknown reason, the case was reported to the police, and later it was found that the patient

died because of several reasons such as liver cirrhosis, lipoid anemia, coronary artery disease and
the cause of death is probably a cardiac arrest.
Analysis and strategies
Therapeutic communication is one of the key aspects of this case study. It is a process
that facilitates a face to face interaction primarily focused on the emotional and physical
wellbeing of the patient. Healthcare providers use this communication to provide information
and support to the patient. There is a variety of technologies to achieve it. However, the use of
these techniques must be perfect and needs proper training to achieve it in clinical settings
(Bogner, 2018). Another aspect of clinical care is accountability. It is considered to be the heart
of nursing that helps in weaving the wave through in every setting and at all level of the
profession. It is also an energizing force within the healthcare organization. The existence of
accountability culture in the healthcare organization, healthcare workers, will understand their
responsibility and will perform their duties as per the care ethics and standards. The organization
that lacks accountability gives excuses when they fail to meet the objectives (Hacker & Walker,
2013). The staff thinks that they are quite close to the desired target and fail to recognize the
difference. The presentation of Roy on 3rd day was quite inappropriate as the nurses fail to
recognize the abnormal vital signs and they also didn’t recognize the alternative diagnoses. They
also didn’t consider the referral to critical care physician and emergency care unit. Further, the
review committee also identified that the care required for Mr. Roy was beyond the scope of
resources available that can help in the improvement of his condition (Marik, 2017).
The failure to recognize the clinical deterioration and responding to it swiftly is one of
the key issues these days within clinical settings. One of the major factors associated with it is
non compliance of the clinical staffs towards effective patient’s monitoring. The monitoring of
patient within the community or general hospital is mostly based on the intermittent monitoring
and measurement of vital signs such as temperature, blood pressure, etc by the healthcare staff
present in the hospital (Moore,2018). It has been reported that with several hours passes by the
measurement, and the deterioration of the patient generally goes unnoticed. Further, the
interpretation and integration of the information achieved through the measurements remain very

important for the clinical judgment of the patient. In this case, Mr. Jacob’s vital signs
measurement might not be taken appropriately, and it may be one of the major reason for her
clinical deterioration (Haegdoron et al., 2018). The monitoring of the patient is quite intense in
operation care and intensive care units. It is quite likely that the early identification of the clinical
deterioration will help in understanding the situation and plan an immediate nursing intervention
for the patient. The regular monitoring of the patient is very important as it may help in the
identification of complication, which cannot be identified with intermittent monitoring of the
patient (McClave et al., 2016). Early identification of Jacob’s case could have tailored
appropriate management and therefore help in reduction of the need of high care requirement and
reduces the length of stay in the hospital, reduces hospital admission, time and cost and improve
the survival chances of the patient. The monitoring of the patient is known to be inappropriate in
most of the hospital because of either lack of appropriate equipment, lack of expertise of the
clinical staff in clinical data interpretation, high patient to staff ratio etc increasing the load on
the staff in monitoring of the patient (Cho et al., 2016).
Another factor that is responsible for unrecognized clinical deterioration and responding
to it swiftly is lack of adequate training and knowledge of the clinical staff. Even if they commit
some mistake, they try to avoid it and lacks accountability. Serious adversity may occur such as
unplanned admission in intensive care unit or cardiac arrest because of under treatment of
clinical deterioration or unrecognized vital signs of the patient. It has been reported that about
one in 20 patient admitted in the hospital shows the signs of clinical deterioration that are more
than enough to warrant the clinical intervention to the patient by the nursing staff (Vincent et al.,
2018). Results also suggest that the nurses do not properly identify the warning signs because of
lack in accountability and clinical communication between the healthcare staff. The
unrecognized clinical deterioration, failing in alternative diagnoses and lack of emergency
response to the patient’s condition, delay the response to the intervention leads to increase in the
risk of mortality of the patient (Lam & Flabouris, 2017).
Misdiagnosis and failure to perform alternative diagnosis is one more issue that add on to
failure to recognize clinical deterioration. The failure of the clinical staff in diagnoses or
misdiagnosis of a particular illness becomes the basis of medical malpractice and misconduct of

the nursing codes of practice. The misdiagnosis of a patient’s clinical condition is not always
malpractice in medical service, and not every error in diagnosis may give rise to a lawsuit.
Reports suggest that even very highly qualified and experienced doctors may make a certain
error in diagnosis (Bonger, 2018). It should be understood that the case of misdiagnosis is merely
a result of delayed treatment, miscommunication, lack of proper medical care and no timely
treatment that result in the worsening of the patient’s condition. The cases of misdiagnosis may
also involve a false diagnosis, delayed diagnosis, and failure of the clinical staff to recognize the
main reason of clinical complications result in aggravation of the condition of the patient. There
are scenarios where the doctors fail to recognize one condition and understand the fact that it is
important to make an alternative diagnosis to treat the patient in an appropriate manner
(Callaghan et al., 2017). The improper diagnosis of Jacob in the hospital may have caused
because of a lack of proper facility, reduced time and pressure on the clinical staff that regularly
monitor the vital signs and help the physician to make an appropriate diagnosis, etc. The unusual
illnesses are difficult to get diagnosed such as in the case of Jacob. It was diagnosed that he had
pneumonia; however, after the autopsy; it was found that he was suffering from liver cirrhosis
and was a long term abuser of alcohol. He died because of cardiac arrest, and it must have been
recognized using the regular monitoring of the vital signs such as pulse rate and blood pressure
etc. The nurses must have performed ECG test as well or must have kept a regular monitor of the
cardiac function. For instance, in Jacob’s case, he was admitted to the hospital after consuming
alcohol and the doctor failed to make a correlation between his current health condition and his
past medical history. Jacob was having cardiovascular issues and that must be the major reason
of his sudden death by myocardial infarction. The hospital staff must have referred Jacob to a
more experienced doctor or could have send him to the emergency unit in another hospital for a
proper diagnosis and treatment
Conclusion
Improved monitoring of the patient on the low acuity ward is highly needed to reduce the
rate of failure to rescue. It is not always possible to regularly monitor the patient in a general
ward, but the general body of medical care is now demanding the need of a proper tool for

regularly monitoring the vital signs of the patient so that a differential and alternative diagnosis
can be made appropriately (Bruin, 2018).

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