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National Safety and Quality Health Service Standards

Coordinated care delivery is one of the main aims of the healthcare personnel as required by a patient. In doing so, the needs of the patient are needed to be considered and the focus is to be given upon the wellbeing. The Australian Commission on Safety and Quality in Health Care has outlined a standard care procedure that ensures that patients are receiving comprehensive care that are sufficient for meeting their needs and reduce the impact of their health issues on their life and well being. The current study aims at finding out the gaps identified in the case study “Hospital staff failed to provide care to elderly patient who died from severe bedsore”, its consequences upon nurse, patient and patient’s family and to develop an action plan that would be helpful in improving care safety and quality in the context of nursing.

Thesis statement: Incorporation of safe and quality care practice in nursing can be beneficial to the health and wellbeing of a patient.

Mr. McBride, 86 year old former harness racing trainer died of multi-organ failure due to severe bedsore that he had developed while seeking care at Port Pirie Hospital as reported by the state coroner Mark Johns (ABC News, 2020). It has been identified that the hospital staff members we incapable of providing adequate care support to the patient. Failures in taking medical notes adequately by the staff members have been identified along with reluctance in following the best-practice treatment methods. Apart from that, catheter and sedative drugs have also been used unnecessarily. There was also a lack of communication between the hospital doctors identified. As per the expert geriatrician associate Professor Craig, the bed-centered care and unnecessary use of anti-psychotic medications led to ultimate immobility due to the effects of sedatives. This incident led the family members of Mr. McBride into distress. Therefore, it can be stated that the care practice followed in the case of current patient ultimately led to negative consequences.

As the nurses of the Port Pirie Hospital have been ultimately held responsible for the death of Mr. McBride, it is likely for the nurses to face some consequences as per the guidelines of Nursing and Midwifery Board of Australia (Nursing and Midwifery Board of Australia, 2020). Nurse practitioners can be taken under direct scrutiny based on the nursing report received by NMBA (Nursing and Midwifery Board of Australia, 2020). As per the “Sections 156(1) and 157 of the National Law”  NMBA can take immediate action against the nurses in order to protect the public interest; even, nurses accused for this misconduct mentioned earlier can be punished by 12 months imprisonment or more (Nursing and Midwifery Board of Australia, 2020). As a result of the misconduct, Mr. McBride has faced difficulties in moving leading to develop bedsore that is the ultimate reason for multi-organ failure and death (McDonald et al., 2017).The family members have also faced distress as the consequences of the incident. Therefore, in the decision making process, family members of Mr. McBride were not involved due to which they could not contribute to the care for their patient.

Activity 4



Lack of risk assessment

Opportunity to improve care plan in future

Death of the patient


Distress of family members


In order to prevent the incident from occurring further nurses of Port Pirie Hospital are required to develop an action plan. Through the action plan, the nurses will be able to improve their practices.

In order to provide comprehensive care clinical governance and quality improvement is required where they can apply quality improvement systems. According to Ariosto et al., (2018), nurses can monitor the delivery of comprehensive care, develop and apply strategies so that the outcomes of the comprehensive care can be improved. As per Siman & Brito (2017), Nurses could also involve in screening risks by taking history to assess the current status of the patient and changes in requirement during care (Australian Commission on Safety and Quality in Healthcare, 2020). Comprehensive care as the end of life is meaningfully effective to the patient if the nurses can ensure that the care process of tolerable and receivable by the patient (such as use of using sedative drugs). In addition to this, Watkins, Dewar & Kennedy (2016) stated that constant communication with the specialist palliative care advice is also needed to be taken through collaboration. It is also a responsibility of the nurses to minimize the risk of harm to the patient. Specifically, the family members are also needed to be provided with information regarding the management of pressure injuries (Sonğur et al., 2018). Apart from that, Phillips, (2019) mentioned that physical and chemical restraints are also needed to be administered carefully following standard practice regarding the same. Therefore, in doing so, nurses are required to need to prevent and manage the pressure injuries.

Activity 5

Nursing actions

1. Worthwhile communications (Mohammadipour et al., 2017)

2. Electronic and audiovisual programs for better monitoring (Edelman et al., 2020)

3. Empathy towards elderly people (Gholamzadeh et al., 2018)

4. Coordination of care (Obioma, 2017)

5. Establishment of deeper connection with others (van Vliet, Jong & Jong, 2018)

Personally, it can be stated that the nurses could have focused on the risk measurement process through which the condition of the patient could be easily identified (Nursing and Midwifery Board of Australia, 2020). Due to lack of understanding of the patient need and comprehensive care planning the current incident took place. The reluctance of the hospital staffs to include the family members into the care planning can also be considered as a cause of death of Mr. McBride. I have learnt from the current incident that nurses are required to take immediate and comprehensive action to comfort the patient they are responsible for. A regular improvement in the care plan with the changing need of the patient is needed to be considered. Considering the current understanding and learning, partnership with the family members can be established to ensure effective care. In conclusion, in a comprehensive care system, nurses are required to take possibly effective actions to meet the changing needs of the consumer. A constant evaluation of the patient’s health status, along with partnership with the family members can help in reducing specific harm to the patient. Therefore, as stated earlier, incorporation of safe and quality care practice in nursing can be helpful in achieving health related outcomes and wellbeing of a patient.

Reference List for National Safety and Quality Health Service Standards

ABC News, (2020), Hospital staff failed elderly regional patient who died from bedsore. (2018). Retrieved 23 August 2020, from https://www.abc.net.au/news/2018-09-07/staff-failed-to-provide-care-to-elderly-patient/10214890

Ariosto, D. A., Harper, E. M., Wilson, M. L., Hull, S. C., Nahm, E. S., & Sylvia, M. L. (2018). Population health: a nursing action plan. JAMIA open1(1), 7-10.Retrieved 23 August 2020, fromhttps://academic.oup.com/jamiaopen/article-pdf/1/1/7/31500945/ooy003.pdf

Australian Commission on Safety and Quality in Healthcare, (2020), Comprehensive Care Standard Retrieved 23 August 2020, from https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard

Edelman, L. S., McConnell, E. S., Kennerly, S. M., Alderden, J., Horn, S. D., & Yap, T. L. (2020). Mitigating the Effects of a Pandemic: Facilitating Improved Nursing Home Care Delivery Through Technology. JMIR aging3(1), e20110. Retrieved 23 August 2020, from https://aging.jmir.org/2020/1/e20110/

Gholamzadeh, S., Khastavaneh, M., Khademian, Z., & Ghadakpour, S. (2018). The effects of empathy skills training on nursing students’ empathy and attitudes toward elderly people. BMC Medical Education18(1), 198. Retrieved 23 August 2020, from https://link.springer.com/article/10.1186/s12909-018-1297-9

McDonald, J., Cumming, J., Harris, M., Powell Davies, G., & Burns, P. (2017). Systematic review of comprehensive primary health care models.Retrieved 23 August 2020, from https://openresearch-repository.anu.edu.au/bitstream/1885/119212/4/appendix_62644.pdf

Mohammadipour, F., Atashzadeh-Shoorideh, F., Parvizy, S., & Hosseini, M. (2017). Concept development of “Nursing presence”: Application of Schwartz-Barcott and Kim's hybrid model. Asian nursing research11(1), 19-29. Retrieved 23 August 2020, from https://www.sciencedirect.com/science/article/pii/S1976131717300749

Nursing and Midwifery Board of Australia, (2020). Guidelines: For nurses applying for endorsement as a nurse practitioner . Retrieved 23 August 2020, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines/Guidelines-on-endorsement-as-a-nurse-practitioner.aspx

Nursing and Midwifery Board of Australia, (2020). Registered nurse standards for practice . Retrieved 23 August 2020, from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Nursing and Midwifery Board of Australia, (2020). Safety and quality guidelines for nurse practitioners . Retrieved 23 August 2020, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines/Safety-and-quality-guidelines-for-nurse-practitioners.aspx

Obioma, C. (2017). Improving the Quality of Nursing Documentation in Home Health Care Setting. Retrieved 23 August 2020, from http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=4603&context=dissertations

Phillips, A. (2019). Effective approaches to health promotion in nursing practice. Nursing Standard.Retrieved 23 August 2020, from https://repository.canterbury.ac.uk/download/ba8d23f2eefc93d53cf7d4a60ed730fa98772d192a7cd1830856dbaf38ecb9b8/283476/Effective%20approaches%20to%20health%20promotion%20in%20nursing%20-%20Nursing%20Standard%20Oct%202018.pdf

Siman, A. G., & Brito, M. J. M. (2017). Changes in nursing practice to improve patient safety. Retrieved 23 August 2020, fromhttps://www.locus.ufv.br/bitstream/handle/123456789/12785/en_0102-6933-rgenf-1983-14472016esp68271.pdf?sequence=1

Sonğur, C., Özer, Ö., Gün, Ç., & Top, M. (2018). Patient safety culture, evidence-based practice and performance in nursing. Systemic Practice and Action Research31(4), 359-374. Retrieved 23 August 2020, from https://www.researchgate.net/profile/Oezlem_Oezer/publication/320213999_Patient_Safety_Culture_Evidence-Based_Practice_and_Performance_in_Nursing/links/5a242ac4a6fdcc8e8668ed55/Patient-Safety-Culture-Evidence-Based-Practice-and-Performance-in-Nursing.pdf

van Vliet, M., Jong, M. C., & Jong, M. (2018). A mind–body skills course among nursing and medical students: A pathway for an improved perception of self and the surrounding world. Global qualitative nursing research5, 2333393618805340. Retrieved 23 August 2020, from https://journals.sagepub.com/doi/pdf/10.1177/2333393618805340

Watkins, S., Dewar, B., & Kennedy, C. (2016). Appreciative Inquiry as an intervention to change nursing practice in in-patient settings: An integrative review. International Journal of Nursing Studies60, 179-190.Retrieved 23 August 2020, from https://rgu-repository.worktribe.com/preview/293125/WATKINS%202016%20Appreciative%20inquiry%20as%20an%20intervention.pdf

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