Complex Care Assessment: Patient Safety and RN Role in NUR331

This report analyzes a case study involving a patient, Jane Hughes, who experienced a medication error due to communication failures among medical staff. The report applies the National Safety and Quality Health Service (NSQHS) Standards, specifically Standard 4 (Medication Safety) and Standard 5 (Patient Identification and Procedure Matching), to identify the issues. It examines the role of Registered Nurses (RNs) in preventing such errors, referencing the Nursing and Midwifery Board of Australia (NMBA) guidelines. The analysis includes recommendations for improving medication management, patient identification, and overall patient safety, emphasizing the importance of training and adherence to established protocols. The report concludes with reflective statements on learning goals related to RN responsibilities and safe practice within a healthcare setting, highlighting the significance of individual accountability and continuous professional development.

WHAT ABOUT GROVER (Student Names here)
Introduction:
Jane Hughes is a patient undergoing a
medical treatment for cancer. However
the patient fall victim of wrong
treatment in the hospital where she
was availing treatment on regular
basis. The lack of communication
among the medical staffs resulted in
the inappropriate injection.
(Imagesante 2019). The case study can
be considered a case in which the
importance of the application of the
standards of National Safety and
Quality Health Service Standard can be
demonstrated.
Step 1: First issue - Communication
Issue
Standard 4 of National Safety and Quality Health Service
Standard is one of the standards that can be applicable in
this case. This standard discusses the aspect of
medication safety. This standard deals with all the aspects
like prescription, dispensation, administration of
medicines. In case of Jane Hughes the error that took
place was the administration of an inappropriate
injection (Australian Commission on Safety and Quality in
Health Care, 2012). Following of the medication
management process stated in this standard would have
contributed in avoiding the accident that took place in
case of Jane Hughes.
The standards that are to be followed under medication
safety provide a list of criteria that are to be fulfilled by
the medical practitioner. The subsection 4.9 of the
standard involves ensuring that the detail information of
the medicine and the decision support tool is available to
the workforce within the clinic during the time the
decision for administration of medicine is done. This
particular subsection is of enormous relevance to the
event in the case study. There are three detailed steps
that are included under this subsection. First is ensuring
that the medication and decision support tool
information is available to the workforce of the clinic who
is responsible for administration of the medicine. Second
aspect is to ensure that the information and support tool
is being viewed at regular interval of time by the people
who are in responsibility of the administration of the
medicine (Safetyandquality 2019). Third step is to ensure
that the process which ensures the availability of
medicine and decision making is upgraded over the
period of time.
RN role and reflection on communication issue
• RNs should develop a planning for nursing practice. The
planning of different nursing practices should be done
by the RNs. They should also take the responsibility to
communicate the practices that are developed.
• RN to ensure that safe and proper service is being given
to the patient. The administration of the right medicine
can be considered as one of the vital safe practices.
(Nursingmidwiferyboard 2019). This is one of the key
standards that have not been implemented in the case
study.
• RN to conduct an assessment comprehensively. The
information that is available to them should be analysed
and communicated to ensure proper treatment to the
patient.
Reflection
The steps that have been mentioned in the standard are
addressed to the nurses. The nurses while giving services to
the patient should have the necessary information readily
available to them. Ensuring that the information has been
checked by them each time they are providing the patients
with treatment is the responsibility of the nurses. The
administration of medicine is one of the most vital
responsibilities that are to be conducted by the nursing staff
(Johnson, 2014). There is no scope of mistake in this section.

Step 2 Second issue - Medication
Error
The standard 5 of National Safety and Quality Health
Service Standard is also relevant in this case. This
standard discusses the patient identification and
procedure matching. This is one of the important
standards that are to be followed by the
clinicians for reducing error in treatment. The
standard 5 ensures that the identification of the
patient is done properly (Healy, 2016).
The sub section of 5.1 states that there are several
steps that has to be taken for the clinicians to
ensure that the patient is properly identified. The
steps stated in 5.1 states that there has to be
patient identifier within the clinic. Sub section 5.1
states that there has to be defined patient
identifiers that are approved present in a clinic.
There has to be 3 identifiers in admission or
registration. In any service or care or therapy
there has to be at least 3 patient identifiers.
During the change or handover of patient it is
important for the clinic to make sure that the
patient identifiers are present (Gardner et al.
2014). In this case the case of Jane Hughes in this
case was handed over from Doctor Livingstone to
Dr Campbell. But Dr Campbell was not prepared
to take the responsibility because of the fact that
there was no training that has been undergone
by the Doctor. These kinds of situations are often
professionally termed as an ‘error trap’. There
was a standard procedure which is called the IT
rules which were placed in the clinic where Jane
Hughes was undertaking her treatment. But the
IT rules have been overruled in this situation
while handing over the responsibility to the Dr
Campbell even after repeated reminder given to
her by her subordinate.
Role of registered nurse in the provision of the
Medication error
The Nursing and Midwifery Board of Australia or
the NMBA provides seven specific guidelines
that are to be followed by the Registered
Nurses. The seven steps has been discussed in
the section below.
• The first standard states that a nurse should
use their thinking and analysing capability for
the purpose of practising their occupation.
The RN should follow the standards but at the
same time should use their experience and
knowledge in practical situation. According to
this standard a nurse should ensure that the
practice is patient centric.
• The nurse should engage in a therapeutic but
professional relation with the patient. In this
case study as soon as the patient Jane Hughes
presented herself after being stressed the
nurse eased her by taking.
• The role of a RN is significant so it is of
paramount importance for them to ensure
that they conduct their duties with personal
responsibility and accountability. They should
have proper training for the practice.
• The nurses tend to play a vital role in the
implementation of the patient safety. The
nursing staffs tend to be in the responsibility
of monitoring the patients and their health
developments. The implementation of the
standards stated in the National Safety and
Quality Health Service Standard are mostly to
be done by the nurses. Some of the
specification of the kind of harms that are to
be avoided by the nurses involves avoiding of
administration of medication. In this
particular case Jane Hughes the
administration of the injection was wrong. In
general in a clinic the nurses are responsible
for the administration of the medicine
(Delaney, 2018). So the duty of the nurse can
be considered to be of importance in this
particular case.
Recommendation
Considering the case study in the section above there are some
fundamental recommendations that can be provided to the nursing
and clinical staff under NSQHS guidelines. It is important for the
nurses and clinical staffs to ensure that medication management
guidelines are regularly followed by them. Only nurses should have
the responsibility for the administration of the medicine especially in
case of vital drugs. It is important to ensure that quality improvement
activities are being undertaken at regular interval of time.
Maintenance of patient documentation should be done by the RN or
any other clinicians that are involved in the activity of patient
treatment. In case of adverse reaction there should be contingency
strategies for dealing with the adverse situation. Therapeutic Goods
Administration should be established for dealing with adverse drug
reaction situations. The reconciliation of documents should be done
when the patient is exchanged between different clinicians when
patient handover is done. High risk medication should be dealt with
proper protocol. Administration of the high risk medication is the
responsibility of the nurse and it is important to ensure that such
medications are administered with utmost security. There should be
an organisation wide system in place for the purpose of patient
identification (World Health Organization, 2010). The doctors, nurses
or clinicians engaged in patient care should complete their training
before they start their work.
Reflective statements
The standards that have been set are detailed and informative. The
responsibility of the nurses that has been stated in NMBA provide an
in depth knowledge of the responsibility of the nurses. The particular
responsibility that can be established as a learning goal involves the
standard 6 which states the responsibility of the nurses to provide a
safe and appropriate practice for taking care of the patients. The case
study also provides the learning that it should be the responsibility of
each individual being engaged in working in a health care setting to
complete their training. .

Reference List
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.
Delaney, L.J., 2018. Patient-centred care as an approach to improving health care in
Australia. Collegian, 25(1), pp.119-123.
Gardner, G., Gardner, A. and O'Connell, J., 2014. Using the Donabedian framework to
examine the quality and safety of nursing service innovation. Journal of clinical
nursing, 23(1-2), pp.145-155.
Healy, J., 2016. Improving health care safety and quality: reluctant regulators. Routledge.
Imagesante (2019). Just an ordinary day | Imagésanté. [online] Imagesante.be. Available
at: https://www.imagesante.be/en/films/2004/just-an-ordinary-day [Accessed 10 Oct.
2019].
Johnson, A., 2014. Health literacy, does it make a difference?. Australian Journal of
Advanced Nursing, The, 31(3), p.39.
Nursingmidwiferyboard (2019). Nursing and Midwifery Board of Australia - Registered
nurse standards for practice. [online] Nursingmidwiferyboard.gov.au. Available at:
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards/registered-nurse-standards-for-practice.aspx [Accessed 10 Oct. 2019].
Safetyandquality (2019). [online] Safetyandquality.gov.au. Available at:
https://www.safetyandquality.gov.au/sites/default/files/migrated/ASQFHC-Guide-
Healthcare-team.pdf [Accessed 10 Oct. 2019].
World Health Organization (2019). Learning from Error - video and booklet. [online] World
Health Organization. Available at:
https://www.who.int/patientsafety/education/learning_from_error/en/ [Accessed 10 Oct.
2019].
World Health Organization, 2010. Patient safety workshop: learning from error.