Patient Safety In Nursing

Patients Safety is the most crucial about healthcare sector around the world. It is defined as ‘the prevention of patients harm’ (Kohn et al. 2000). Even thou patient safety is shared among organization members, Nurses play a key role, as they are liable for direct and continuous patients care. Nurses should be capable of recognizing the risk of patients and address it to the other multi disciplinary on time.

However, we are looking at a case study where patients safety has been compromised, professionalism has been voided, lack of communication, nurses aren’t liable for their work, the duty of care has been breached and lot more issues can be discovered. Which will be incorporated in this paper. Looking at the patient Christopher Hammett

who was suffering from unresolved back pain. On 23, December 2004 Christopher was referred to Dr. Scott-young for his back pain. Dr. performed an orthopedic review on him again Dr. Scott performed further orthopedic review where he also signed a consent form for an L5-S1 disc replacement operation. On 22 April Dr. Scott operated Mr. Hammett and the anesthetist was Dr. Dennis Wooller. The operation took 53 minutes and Mr. Hammett’s oxygen saturation was maintained at 99% and was transferred to post anesthetic care unit. At the time of transferring him his oxygen saturation, DE saturated but the first record in PACU is recorded as 64%. He was also given 4mg morphine before discharging him to accommodation unit from PACU. The RN Manton was the one receiving him and during the handover, it’s said that RN Turrell from PACU didn’t advise her of the desaturation event. During the time, there were two other RN looking after him as well RN Gibbons and EN valentine. Those two nurses were present at the time of the main event when MR Hammett’s oxygen saturation dropped to 69% and later on he was unconscious which lead to his death due to aspiration pneumonia as a consequence of coronary atherosclerosis.

What the inquest have discovered is that Mr.

Christopher death could have been avoided if the Doctor had been able to identify the cause of his desaturation on time. Due to lack of nursing care and many human errors from both the medical team and nurses, it leads to his death as per the inquest. Patient safety was compromised. It was found that Dr. Wooller the anesthetist and Dr. Young the surgeon who operated on Mr. Hammett didn’t investigate on the significant oxygen desaturation event that occurred in PACU while he was transferred from Operation Theater. DR. young assumed it was due to obstructed airway. As Mr. Hammett had Guedels inserted. The inquest stated that the anesthetist was supposed to review the arterial blood gas and transferred Mr. Hammett to High dependency unit due to his desaturation event for more than 20min. The nurses looking after MR. Hammett in PACU was RN Turrell and RN Proud. RN Proud notified Dr. Woller about the desaturation event for which doctor paid the visit but didn’t physically examine Mr. Hammett and left with short conversation. If Dr. Woller had investigated the cause of desaturation event at that time probably they could have prevented the rest desaturation event but unfortunately, none of them were implemented, which lead to additional complication Following the event the deceased was administered bolus morphine for his pain, which was scored 4/10. The nurses working in PACU RN Proud notified the anesthetist about the oxygen stat

however they didn’t document that Mr. Hammett was administered two additional morphine doses while he was in PACU. The inquest found out that the stay in PACU was too brief despite the desaturation event and his unmanaged pain. Morphine is a narcotic drug, which can compromise the respiration. After administering morphine we need to observe the patient for at least 30min but none of this was done therefore the nurses breached the protocol, failed to implement the policy, didn’t document the two additional bolus morphine.

Despite all the desaturation event and poor pain management in PACU it was noted that he was in fully recovery state with the score of 10/10. Which is not true. Mr. Hammett was transferred to the ward. The nurses responsible for Mr. Hammett care were RN Manton and EN valentine. While he was in ward Mr. Hammett had episodes of desaturation event. RN Manton treated the desaturation by increasing the oxygen level. Hammett was in lot of pain as the narcotic infusion record shows he requested for pain relief 125 times over a two hours period but during the inquest Manton said Hammett didn’t have any pain. Manton didn’t notify the Dr. Woller about the event. He ignored Doctors prescription and applied his own theory on bases of his own experience that is not professional and he breached the standard of care. Then later in a night shift RN Gibbons and EN valentine was responsible for Mr. Hammett during their shift Gibbons left Valentine to look after all the patient on that shift and solely depended on Valentine. Gibbon has purely demonstrated the lack of participation in that shift. There were many episodes when the oxygen level was playing up as Hammett took off the mask constantly whoever EN Valentine assumed that it was the reason for low oxygen saturation. Where as Gibbon once used a re breather from the emergency trolley and failed to realize that Hammett needed emergency help at that time. The inquest has stated that Gibbon lack of participation can be descried as unprofessional and lack of care one would expect from a Licensed Nurse.

THE TORT OF NEGLIGENCE

McDonald & Then (2014) states that ‘the following four elements must be proven to be successful in a suit for negligence, which are if duty of care was owned by the plaintiff, the defendant fell below the required standard of care, the breach of duty caused damage and if the loss or damage suffered was reasonably foreseeable.’

Patient safety is a core responsibility of a nurse.

Nurses come in direct contact with the patients and their families. Therefore nurses are held liable for their work. Negligence is when nurses fail to perform according to the standard of care that results it any kind of harm, damage or death of a patient. If the patient suffers any of the problems they have a full right to bring legal action against the nurse for negligence. Negligence can be civil or criminal. In this case we can look at RN Manton he has shown negligence with his duty of care towards Mr. Hammett therefore he is liable for his death. We have observed that Manton didn’t follow the hospitals protocol during the desaturation event and treated Mr. Hammett on bases of his own experience. Manton admitted that he had ignored the prescription from Dr Woller in relation to oxygen that indications negligence. This shows he has failed to apply his skill and knowledge in this case He also relied on EN valentine to do all the observation and look after the patient on that shift which shows Manton being irresponsible towards his duty of care. He should have check on Hammett himself and monitored

him.

Watkins, Whisman & Booker, 2015) states that response to abnormal vital signs in most vital levers in patient safety, by delivering timely recognition of early clinical deterioration. Therefore, RN Manton is accountable for the deterioration of Hammett. As, he didn’t communicate about the event to the doctor. He didn’t perform any skill that was vital for Mr. Hammett at that time. Due to lack of communication the possible chance of treating Hammett was delayed. Not reporting it to the doctor has caused Mr. Hammett death. He kept increasing the oxygen saturation in ward on his own knowledge base without any protocol.
During the event of desaturation Gibbons used a re breather mask from the emergency trolley and failed to realize that the situation was and emergency event he should have treated it as an emergency at that point. This only shows that Gibbons showed carelessness and didn’t take his role as a nurse seriously. (Nursing and Midwifery Board of Australia, 2008) states that if a nurse witnesses any unlawful conduct of colleagues than they should notify the authority to protect the public which we can relate to EN Valentine saw Gibbons removing paper from Mr. Hammett’s chart and altered the observation.

ETHICAL ISSUES

Nursing and midwifery board of Australia provides the guidelines of ethical practice to help nurses understand and make ethical decisions when caring for patients and their families. Nurses are bound to perform professionally and ethically maintaining the standards. Nurses should be reliable for their duty of care.
The code outlines that nurses must respect, be culturally safe, value informed decision making, apply quality nursing care for all people, protect and uphold fundamental rights of self, colleagues, health consumers and community within a safe environment (Nursing and Midwifery Board of Australia, 2008). In this case, RN Gibbon has failed to provide quality-nursing care towards Mr Hammett during his period in the ward. Mr Hammett had all the right to receive quality care from the entire health professional involved in his treatment. Mr Gibbon was supposed to collaborate with the multi-disciplinary team but failed to communicate with Dr. wollerr about the desaturation event he had in the ward. RN Gibbon didn’t notify the Doctor about it. Mr Gibbon has acted unprofessional during the care of Mr Hammett. He solely relied on EN Valentine to look after entire patient that night.
Responding to Clinical Deterioration adds oxygen saturation and assessment of conscious state as essential elements of physiological observations (Australian Commission on Safety & Quality in Health Care 2010) but in this case, RN Gibbon clearly hasn’t acted, as he should have. Nursing and midwifery Board of Australia (2008) states that nurses are accountable for decisions they make regarding a person’s care. RN Gibbon used his own skill and experience to handle the desaturation event rather than following the protocol of the hospital, which also shows that Gibbon is accountable for his action. Recognition of clinical deterioration is primarily a nursing responsibility (Considine & Currey, 2014), which RN Gibbon has failed to do so. Even though he used the re-breather from the emergency trolley he failed to recognize that it was an emergency case. If he had recognized it then the medical team would be able to provide accurate treatment timely.

Everyone in medical professional will come across ethical dilemmas during their practice. However, nurses should maintain professional standards and practice as per the code of ethics from the national competency.

CONCLUSION
Nurses are anticipated to have high standard of care. Understanding the scope of practice and sticking with the regulation provides legal and moral protection for both patients and nurse. It’s not about avoiding the negligence is also about being professional and treating the patient with dignity.