Case Study Analysis: Professional Errors and Nursing Practice, 401021

This case study analyzes a nursing incident involving patient A who died due to a series of professional errors. The case study highlights the failure of nursing staff and management to provide timely and appropriate care, including delayed diagnosis, failure to monitor the patient's deteriorating condition, and lack of communication. The analysis identifies contributory factors such as misdiagnosis, delayed diagnosis, infection risks, and medication errors. The implications for future practice emphasize the importance of accountability, timely diagnosis, patient-centered care, and consultation within the nursing profession. The case study references the National Safety and Quality Health Service Standards and emphasizes how adopting professional behaviors could have saved the patient's life. The assignment demonstrates the importance of adhering to professional standards and the consequences of failing to do so.

Running Head: CASE STUDY 1
Case Study
Students’ Name
University Affiliation
Course Title
Date

CASE STUDY 2
401021 Being a Professional Nurse or Midwife – Assessment 2
___________________________________________________________________________
Criteria 1. Case Summary: Summarizes the case and presenting professional practice
issues.
The nursing case study involves patient A who reports to the nursing staff at 1720 hours
that she has abdominal pain and is feeling dizzy. The nursing staff observed the patient and
found that she has very low blood pressure (89/53) and a heart rate of 88. Furthermore, her
respiratory rate was between 40-44/min. The respondent is advised about patient A's condition
by an enrolled nurse but says the patient will be reviewed after locum arrives. A few minutes
later, the patient respondent is notified about the patient’s continual diarrhea but still insists on
review after locum comes. However, the respondent checks the patient by herself but fails to
document her observations.
At around 1910 hours, the respondent arranges for an extra ECG to be done. One hour ten
minutes later, the nurse manager in the clinical setting makes a call to the respondent regarding
an arrangement for one else (other than A) medication to be acquired from the drug safe. Ten
minutes later, the manager arrived at signed the medication upon arriving at the hospital.
However, the respondent failed to present any concerns regarding patient A. The locum arrived
at 10:00 pm when the patient’s condition had significantly deteriorated. The emergency doctor
arrived one hour later to insert a large bore IV cannula for the management of the patient's
adverse dehydration. More efforts were made to transfer the patient to a rural referral hospital,
but eventually, patient A died.

CASE STUDY 3
Patient's A case is complicated, and the death of the patient was as a result of the
ignorance of the respondents that ought to have been responsible. The authority that is Ms
Catherine Jones, the Clinical Nurse Manager, totally ignored her responsibility by not giving the
required attention to the patient. It was noted that the patient's family was supposed to be
contacted. This means that the condition of the patient was drastically deteriorating. This is
legitimate to prove that the responsible authority ignored the patient's case willingly.
The responsible doctors take more concern about addressing or rather knowing the condition of
the patient rather than diagnosing her. The actions of the competent authorities were
unprofessional. Also, the respondent acts unprofessionally when she fails to record the
observations of the patient. Furthermore, she fails to discuss the patient’s condition with the
manager despite the fact that the patient’s condition was deteriorating. The respondent also
ignores the patient’s diarrhea on the basis that the patient shall be reviewed when locum arrives.
The patient would have been diagnosed immediately on her arrival at the hospital.
Initially, patient A appeared to have abdominal pains, low blood pressure (89/53) and also dizzy.
Any qualified medical practitioner would have been able to know that the patient required a
specific diagnosis.
Criteria 2. Contributory factors: Identify relevant professional errors that potentially
contributed to the incident happening?
Misdiagnosis is one of the significant medical errors (Phillips, Hall, Pearce, Travaglia,
Lusignan, Love & Kijakovic, 2017). Sometimes professional medical caregivers commit this
error while doing their work, whereby they fail to give their patients the required diagnosis
(Klein, 2018). Misdiagnosis is contributed by factors such as errors during lab test experiments,

CASE STUDY 4
medical devices errors, among others, which may end up resulting in different results, thus
misdiagnosis.
Moreover, defective medical devices often result in errors in most hospitals (Lowe,
Plummer, Brien & Boyd, 2012). A type of error as this cannot be prevented a doctor, as they are
not entirely in a position to prevent this type of error from occurring. In such a scenario, the
specialist is not to denunciate but rather the producer of the faulty device bears full
accountability.
Furthermore, delayed diagnosis is also a known professional error in medicine (Lowe &
Plummer, 2019). For instance, the death of the patient in the case study has been caused by
delayed treatment. It is common among most of the medical practitioners as it has been stated in
a lot of research concerning the unworthy practices in medicine. Late diagnosis can easily result
in the death of the patient, and that is the reason why the medical practitioners should ensure that
their patients are attended to on time and given the right diagnosis.
In addition to other errors, Infection is also jeopardy of nearly any clinic stay or
therapeutic process (Ferrell, Connor, Cordes, Dahlin, Fine, Hutton & Zuroski, 2007). Most
infirmary contaminations are not severe, and treatment can be carried out. However, some
infections can turn out to be extra severe.
Finally, the other error is a medication error; one among the common blunders that
happen in the sequence of therapeutic handling (Slade, Manidis, McGregor, Scheeres, Chandler,
Stein-Parbury & Matthiessen, 2015). Recommending the incorrect dosage or lack of
accountability for medication interactions can result in damaging impacts on the affected. The
pharmacists and prescribers essentially deliberate the medicinal history of the patient to ensure

CASE STUDY 5
that there are no allergies and possibly damaging effects that may result from the drug before
directing the tablets. In case of failure to do so, the patient can experience severe damages.
Criteria 3. Implications for future practice: Discussion that includes how your practice
might change and develop as a result of this learning. What professional behaviors may
have made a difference in this situation?
There are a lot of common mistakes that occur in the course of medical treatment (Adam,
Osborne & Welch, 2017). I do not commit the error of delayed diagnosis to my patients
(Spigelman & Rendalls, 2015). Timely diagnosis is fundamental in the nursing profession
(Australian Commission on Safety and Quality in Health Care, 2012). Also, I have learnt that
providing patient-centred care is significant (Australian Commission on Safety and Quality in
Health Care, 2012). In this case, addressing the patients concerned would have saved the
patient's life. Also, family-centred care is advocated in the nursing profession (Australian
Commission on Safety and Quality in Health Care, 2012). In the case provided, the family was
contacted at the wrong time when the patient’s condition has already deteriorated.
What professional behaviors may have made a difference in this situation?
Several professional behaviors would have been adopted to make a difference in this
case. For instance, accountability in the nursing profession is vital (Australian Commission on
Safety and Quality in Health Care, 2012). The respondent would have been accountable to record
any changes in the patient’s condition. Also, the respondent would have made a timely diagnosis
to the patient. Consultation also plays a significant role in the nursing profession (Australian
Commission on Safety and Quality in Health Care, 2012). In this case, the respondent would
have discussed with the manager regarding the condition of the patient. Patient-centred care

CASE STUDY 6
would have also made a difference. Handling the patient’s diarrhea condition would have saved
the patient’s life.

CASE STUDY 7
Reference
Adam, S., Osborne, S., & Welch, J. (Eds.). (2017). Critical care nursing: science and practice.
Oxford University Press.
Australian Commission on Safety and Quality in Health Care. (2012). National Safety and
quality health service standards. Australian Commission on Safety and Quality in Health
Care.
Ferrell, B., Connor, S. R., Cordes, A., Dahlin, C. M., Fine, P. G., Hutton, N., ... & Zuroski, K.
(2007). The national agenda for quality palliative care: the National Consensus Project
and the National Quality Forum. Journal of Pain and symptom management, 33(6), 737-
744.
Klein, T. (2018). Credentialing the nurse practitioner in your workplace: Evaluating scope for
safe practice. Nursing administration quarterly, 32(4), 273-278.
Lowe, G., & Plummer, V. (2019). Advanced Practice in Nursing and Midwifery: The
Contribution to Healthcare in Australia. Advanced Practice in Healthcare: Dynamic
Developments in Nursing and Allied Health Professions, 51-63.
Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify–the value of
advanced practice nursing roles in health care. Journal of advanced nursing, 68(3), 677-
685.

CASE STUDY 8
Phillips, C., Hall, S., Pearce, C., Travaglia, J., de Lusignan, S., Love, T., & Kijakovic, M. (2017).
Improving quality through clinical governance in primary health care.
Slade, D., Manidis, M., McGregor, J., Scheeres, H., Chandler, E., Stein-Parbury, J., ... &
Matthiessen, C. M. (2015). The context of communication in emergency departments.
In Communicating in Hospital Emergency Departments (pp. 25-54). Springer, Berlin,
Heidelberg.
Spigelman, A. D., & Rendalls, S. (2015). Clinical governance in Australia. Clinical Governance:
an International Journal, 20(2), 56-73.