Risk Management and Health Safety: A Case Study Analysis Report

This report presents a comprehensive analysis of a case study concerning risk management and health safety within a healthcare setting. It focuses on the case of Troy Almond, a pediatric patient, and examines the communication failures and missed opportunities that contributed to his death. The report delves into the role of nurses and doctors, highlighting discrepancies in electronic communication, inadequate assessment of vital signs, and the absence of proper escalation systems. It discusses the importance of early warning tools, documentation policies, and the implementation of protocols like Ryan's Rule and REACH. Furthermore, the report critiques the hospital's poor risk management policies, particularly the ineffective use of the iView system and the failure to adhere to sepsis guidelines. Recommendations include mandating the use of the BTF methodology, enhancing communication between healthcare professionals, and improving handover processes to ensure patient safety and quality of care. The report concludes by emphasizing the need for improved interpersonal relationships and the implementation of effective warning tools to prevent similar incidents in the future.

Running Head: case study
Risk management and Health Safety
Name of the Student
Name of the University
Authors Note

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Introduction
Nurses and the healthcare professionals have vital role in communicating with the
patient’s family and the other health professionals. National Safety and Quality Health
Service Standards have established different facilities for improving the quality of
communication and widening the range. The communication is important in reporting
patient’s deterioration and in connecting a health professional to other for discussing the
better interventions. Communication and proper documentations are very much related to
each other in the field healthcare (Redley, Botti, Wood & Bucknall, 2017). Standard six of
NSQHS is focused on transferring the information regarding critical patients and proper
identification of the patient care in terms of person to person communication. Evidence of a
patient’s treatment will be collected from the cues of inter-professional communications.
Significance of usage of the early warning tools and the escalation systems will help in
indicating different causes of patient’s deterioration. Different other protocols are present in
the sector of healthcare to investigate the reason of a patient’s death. The Coroners Act 2009
states that the inquests determine the causes of death with analyzing the underlying factors
and different aspects related to the death of a person. This report is based on different
communication gaps and missed opportunities in communication with the references of the
ineffectiveness of the nurses and doctors to control deteriorating signs of a pediatric patient.
This report will discuss about the limitations and will propose some recommendations for the
case study of Troy Almond, who died due to lack of efficiencies of the healthcare
professionals.

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Discussion
Missed opportunities and areas of gaps in the RN’s electronic communication
The case study shows that Troy Almond was admitted to the hospital (Shoalhaven
District Memorial Hospital) by Ms Macklin, registered Nurse of the hospital. When the boy
admitted (10:15am on 21 March 2016) to the hospital, RN Pamela Mason examined him and
all the vital signs were recorded by her in the electronic medical records (Coroners Court of
New South Wales, 2018). She assessed that the Capillary refill rate is brisk in him but she did
not measure his blood pressure which is very important vital sign. After that she allocated
troy in Triage category 3 and transferred him to the Pediatric department. She completed the
triage assessment and handed over Troy to the present RN in Charge and to the doctor of the
pediatric bay, Dr Babak Tajvid as shift of the paediatric RN had not commenced. The
allocated nurse of that department was RN Shaun Avis and he joined between 10.50am and
11.00am. He recorded his observations in the EMR by using iView. RN Avis reported that
the doctor recorded the vital signs and assessed the boy at the same time when was assessing
the patient. The medication chart gave the evidence that the doctor should have assessed the
patient at 11.30am when he gave the doses of Panadol and Nurofen. At 12.30 pm, RN Avis
noticed that he had rashes. However the plan of insertion of cannula was intended at 1.06 pm.
During the investigation the expert Professor Raftos showed that the heart rate of the patient
must be noted down and the allocated health professional should opt for blood tests (Coroners
Court of New South Wales, 2018). However the RN and the doctor emphasized on the
appearance of the patient. During the investigation, the RN recalled that the rashes were
blanching, which was not mentioned in the documentation. The inquest shows that a lots of
confusion were present in the time of discharge of Troy. Dr. Tajvidi did not assessed Troy
and referred any blood tests for him before discharging him. There were lots of confusion in
the evidence given as per the RNs and the doctor about Troy’s clinical appearance. Ms

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Macklin sent a message to Mr. Almond and informed that she was waiting for Dr. Tajvidi
who would return to see Troy. Through the message, it could be understood that the doctor
decided to discharge Troy without checking him and referred the blood test.
Importance of electronic communication and the accountability of RNs
Lack of interpersonal training and communication will help the nurses and doctors to
treat a patient effectively. The handwritten and electronically stored documents are important
for the treatment and for keeping the track of deterioration of the patient. The case study has
shown that different discrepancies are present during treating Troy. The investigation of this
case study has shown that the boy was suffering from bacterial infection and the allocated
doctor assumed that the boy was suffering from the viral fever. Doctor did not ask the nurse
to assess the reason behind Toy’s elevated heart rate. He only checked the vital signs and the
expression of the child. As per the experts, Troy was introduced to toxicity at the very
beginning of the symptoms. However the RN Avis neglected the expression of rashes which
were blanched in nature and he reported it as non-blanched with the progression of the
disease the RN and the doctor could have opted for blood test but did not do that. The
experts of the investigation has agreed that the doctor might have thought that the patient was
affected by viral infection as symptoms were very ambiguous. However, the key documents
has shown that RN must consider the Sepsis Pathway for a paediatric patient. As per the
expert opinion, Troy was affected by the colonization of Streptococcus pyogenes in his nose
and his throat. The evidence showed that ambiguity was present in hospital discharge.
Communication is not limited to person to person interactions but also involves
record keepings and documentation. The communication among the clinical professionals is
integrated with the decision making and cue collecting skills. Nurses should enhance the
critical thinking ability and logical reasoning. The handover processes were not executed

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clearly which has been observed in many sectors of the treatment procedure. According to the
NSQHS, decision making is very important in treating the patient (Australian Commission on
Safety and Quality in Health Care, 2020). The case study has shown the failures of nurses and
doctor in involving the patients as partners and in preventing bacterial infection and
contamination.
Rationale of early warning tools and documentation policies
According to the assessments of the patient, Tory’s pulse rate was at the red zone
while the temperature was in the yellow zone. As he was in Emergency Department of Care,
the pulse rate was in the yellow zone or at the borderline of the red range. BTF or Behind The
Flag approach must be used to understand the patient’s condition as per the standard methods
(Pain et al., 2017). The patient’s vital signs are evaluated by the help of color coded chart by
this strategy. The pediatric patients aged between 1 to 4 years must be evaluated by the help
of the Standard Paediatric Observation Chart (“SPOC”). Both RN Mason and RN Avis did
not followed the colour coded BTF method and the SPOC to keep a track of the health status
of the patient. The FirstLine computer system iView was used to keep track of the patient’s
status. The electronic medical report system did not have any colour coding protocols and the
regions to indicate specific abnormalities. The program is used for early detection of
deteriorating signs. The hospital was failed to maintain the “Recognition and Management
Policy” of NSW Health. As the policy was aimed to monitor effectiveness of nurses and
doctors by giving trainings and education. They failed to evaluate Sepsis Pathway of
infection for lack of high level of parental concern. They should evaluate the blood test to
evaluate erythrocyte sedimentation rate (“ESR”), C-reactive protein (“CRP”) and
Procalcitonin rate in the blood. These would definitely indicate the presence of bacteria in the
bloodstream of the patient.

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Escalation systems –Ryan’s Rule
Hospitals should maintain an escalation system or protocol for tracking abnormal
physiologies and observations. The escalation system helps to identify flaws and gaps in the
treatment (Gill, Leslie & Marshall, 2016). The physiological observations and abnormalities
are recorded with the help of escalation systems. The escalation systems will help to track
deteriorating cues in the patient. Delays and difficulties due to identifying the symptoms
interrupt the treatment process and reduce quality of care of the patient. One of the most
accepted escalation system is Ryan’s rule which is prominent in the hospitals and nursing
homes. There are three steps of this rule such as step 1 involves interactions with the nurses
and then step 2 includes the conversation with the nurse in charge of that shift(Dwyer,
Flenady, Kahl & Quinney, 2020). Following the previous steps, step 3 will be decided by the
parents of the patient. In step 3 the parents should inform the governing body of NSW health
and welfare to review the hospital facilities. NSW has own version of this escalation system
named REACH. “REACH” stands for “Recognize”, “Engage”, “Act” ,”Call” and “Help”.
These are the consecutive steps which should be followed by the parents of the pediatric
patient. By following the REACH protocol parents could recognize some abnormalities by
engaging the doctors and the nurses. The parent would inform them to conduct the clinical
review appropriately and then should call the specialist helpline to take action against the
hospital authorities.
Suitable strategies
Troy’s case is the example of poor risk management policy of the hospital. The
doctors and the nurses were not followed the warning signs and were failed to intervene the
solutions for the patient properly (Romero, Fry & Roche, 2017). They used the electronic
medical record system iView which was devoid of warning signs and better interface to
distinguish the signs (Guo, Kim, Smith, & Despins, 2019). As per the report RNs should use

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the BTF methodology to understand the present condition of the patient. They failed to detect
the sepsis pathway by the help of the parental concern guidelines. The report has been
portrayed that the nurses used iView rather than BTF as they felt that it was easier to use and
this is the evidence of lack of training and education. The hospital authority should mandate
the BTF methodology among the nurses. The hospital should implement the guideline to
maintain sepsis guidelines and BTF methodology among the nurses of the emergency
department. The nurses should address NMBA nursing standard and the code of conducts
during the treatment procedures. The clinical committee are active and usable in both the
triage and the emergency department. The clinical governance, leadership and hospital
management will be achieved by the hospital.
Conclusion
The case study concludes that poor communication and interpersonal relationship
should be improved to treat the pediatric patient more effectively. The safety, security and the
quality of the treatment will be improved. Patient and the family members will know the
escalation policy and system to clinically review the effectiveness of hospital. The warning
tools and strategies will help the RNs and the doctors to intervene in a better way. The
handover process must be improved with the communication among nurses and doctors. The
ambiguity and discrepancy can be observed in the hospital and poor framework has affected
the treatment procedure.

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References
Coroners Court of New South Wales (2018) Inquest into the death of Troy Almond.
Retrieved from:http://www.coroners.justice.nsw.gov.au/Documents/Findings%20-
%20Inquest%20into%20the%20death%20of%20Troy%20Almond.pdf
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.DOI:
https://doi.org/10.1016/j.aucc.2019.01.002
Gill, F. J., Leslie, G. D., & Marshall, A. P. (2016). Family initiated escalation of care for the
deteriorating patient in hospital: family centred care or just “box ticking”. Australian
Critical Care, 29(4), 195-200.DOI: https://doi.org/10.1016/j.aucc.2016.07.004
Guo, W., Kim, J. H., Smith, B., & Despins, L. (2019, November). How Nurse Experience
Influences the Patterns of Electronic Medical Record Documentation in an Intensive
Care Unit. In Proceedings of the Human Factors and Ergonomics Society Annual
Meeting (Vol. 63, No. 1, pp. 708-712). Sage CA: Los Angeles, CA: SAGE
Publications. Retrieved from:https://doi.org/10.1177%2F1071181319631052
Pain, C., Green, M., Duff, C., Hyland, D., Pantle, A., Fitzpatrick, K., & Hughes, C. (2017).
Between the flags: implementing a safety-net system at scale to recognise and manage
deteriorating patients in the New South Wales Public Health System. International
journal for quality in health care, 29(1), 130-136. doi: 10.1093/intqhc/mzw132
Redley, B., Botti, M., Wood, B., & Bucknall, T. (2017). Interprofessional communication
supporting clinical handover in emergency departments: An observation
study. Australasian Emergency Nursing Journal, 20(3), 122-130. Doi:
https://doi.org/10.1016/j.aenj.2017.05.003

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Romero, B., Fry, M., & Roche, M. (2017). The impact of evidence‐based sepsis guidelines on
emergency department clinical practice: a pre‐post medical record audit. Journal of
clinical nursing, 26(21-22), 3588-3596. Retrieved from:
https://doi.org/10.1111/jocn.13728
www.safetyandquality.gov.au. (2020). The NSQHS Standards | Australian Commission on
Safety and Quality in Health Care. Safetyandquality.gov.au. Retrieved from:
https://www.safetyandquality.gov.au/standards/nsqhs-standards