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In the case, the issue was the death of Mrs. Mc Judith, due to the Septic Shock experiencing Bilary Peritonitis operated for the bile leak causing generalised peritonitis. The two safety and quality issues that have been identified and analysed in this case are communication for safety and recognizing and responding to the deteriorating patient which relates to NSQHS standards. The RN’s role and clinical governance is discussed in relation to the communication breakdown and the lack of ability to recognise and appropriately respond to a deteriorating patient. By reflecting on the knowledge gained through this analysis, learning goals have been identified which will improve communication skills and ability to respond to the deteriorating patient in clinical practice moving into the transitional year of study (Yimam, et al, 2018). The nursing care plan was not followed, documented and even medication safety practices were not followed (Andrade, et al, 2017).
National Safety and Quality Health Service (NSQHS) Standards, with Standard 4 is related to the medication safety and Standard 6 is for the communicating for safety. In the case safety issues related to the case, and the role of the registered nurse (RN) is to identify how there can be a provision of safe care, and it would lead to recommendations for clinical governance and reflecting on the learning goals from the future practice.
As per the Medications administration the common source of the error in Australian healthcare. In the case, there were several episodes of the medication safety protocols breached causing an impact on the patient’s death. For example, one protocol was the nurse on duty, did not know how to administer the medication and in how much doses.. The other handover nurses were administering wrong doses and medication as there was not documentation of the medicines and the prescription. The nurses on duty due to lack of communication and medication safety, prepared, dispense, prescribe or administer the wrong doses/ NSQHS Standard 4 on medication safety aims to reduce the medical errors in medication management and by providing medical safety during the stages of prescribing, dispensing, administering and monitoring medicines (ACSQHC 2017). Standard 4.1 mentions how the role of clinical governance for the clinicians implement policies have to be followed and 4.15 refers to safe safe management practices of high-risk medications like of the chemotherapy agents (ACSQHC 2017).
Communication is an important aspect and as per the NSQHS Standard 6, through effective communication, a proper transition of the handover of critical information has to be followed (ACSQHS 2017). The role of patient’s doctor for the nurse In-charge has to follow the hospital policy, that belongs from intravenous and intrathecal medications given during the day and she has not conveyed same to the doctor taking over care (Andrade, 2017). It is considered to be critical information which should be handed over for the support of the multidisciplinary team (ACSQHS 2017). In the case, the nurse left and missed handover, leading to the breaches Principle 3.3 of the NMBA Code of Conduct mentions that a nurse should communicate effectively to colleagues (NMBA 2018). Doctor review of nurse and the patient notes with has not occurred and the official patient handover was not documented, leading to misguidance in medication administration, that could follow the safety and continuity of care (ACSQHS 2017). Principle 3.3 of the Code of conduct mentions providing patients with fully communicated information (NMBA 2018).
The role of the RN when administering the safe medication administration is to ensure, they are checking the checking medication orders that are correct and prescribed signed by the doctor (Goebel, et al, 2016). The actions would be responsible to note the administer medications based on the incorrect order. Further to reduce the risk of error RNs, they should cross-check medication after it has been ordered and follow the checks of the medication that goes against the five rights of medication administration (Levett-Jones 2017). It involves the right medication, dose, time, route and patient (Levett-Jones 2017). The RN must administer the risks and gain informed consent and as the RN has not performed her duties to check for three checks and five rights of the medication and doctor failed the before administration (Sobanski, et al, 2020).
The role of the RN is also to handle the communication effectively with timely coordination and also information sharing with the interdisciplinary team to provide patient care (NMBA 2018). During the RN delegates care, it is important to communicate and practice outcomes as per the care and to handle it effectively during the handover. Handover is important, as slightest communication errors can cause an issue. To maintain safe transition and continuity of care, effective communication about patient care plans along with the goals was recommended. No consultation of documentation, disjointed care through the multiple care providers along with the poor patient involvement in the case (Goebel, 2019). The RN's in the case have utilised interprofessional communication during the minimum risk factors. It is also important to improve patient communication during the bedside handover. As per the Bedside handovers, it is important to enhance the patient contribution and also improve the handover quality and ways to reduce the possible miscommunications (Pongjetanapong, 2018).
In my opinion, improved communication can help to provide a safer care transition and less likeliness to reduce the critical information being overlooked. In the case, there has been a significant communication issue, from not following the proper procedure of the various tests or even not administering the various medications, documentation error to the non-following the problems has been one of the urgent problems here. There has been a communication gaps, ineffective handover description and there has been a wrong medication safety guidelines that has not been followed. In my view due to the no communication there would be documented to other members of the ward round or documented within the progress notes. The handover did not know about the triple antibiotics and fluid to administer, due to which her condition has worsened, shows the negligence issue and the lack of care (Trosman et al 2016).
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Australian Commission on Safety and Quality in Health Care (The Commission) 2017b, National consensus statement: essential elements for recognising & responding to acute physiological deterioration, 2nd ed, viewed on 10 October 2019, https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Consensus-Statement-clinical-deterioration_2017.pdf
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