In this assessment, an essay will be made to explain the inadequate care and a systemic hospital failure to recognize signs of a deteriorating patient which lead to Vanessa Anderson death. In November 2005, Vanessa Anderson which was only 16 years of age was hit in the back of the head near the ear with a golf ball. She was drven to Hornsby Hospital and later was transferred to the Royal North Shore Hospital. Due to the inappropriate hospital systems and no communication between all of the departments in the hospital, Vanessa's family suffered a huge shock. She lost her life at a young age due to medical negligence. She was allegedly treated for a fracture to the skull, two days later, she suffered from a seizure and died. However, the coroner …show more content…
determined that Vanessa died from respiratory arrest due to the opiate medication that caused a depressant effect. This case was made a huge focus on the importance of how the hospital systems need to change and the errors in the lack of communication that lead to the loss of Vanessa's life. This essay will hopefully hut some light on the events that lead to the failure of communication in the hospital sector. Furthermore, this essay will give a in sight at the coroner’s findings and will show aspects that led to the death of Vanessa. Frist, The sequence of events of the factors include the following.
The doctors were indecision on whether Vanessa should go to Royal North Shore Hospital. The lack to communicate from Dr. Little, who Vanessa was first admitted to under his care, then a lack of neurosurgery's as they there at training in Melbourne. When Venessa was transferred to Royal North Shore Hospital, she was put under the care of Dr. Bakar, who was performing registrar duties and was overwelled with his work and tired, he was considering anti-convulsants but ever prescribed. Dr. Williams was a senior neurosurgical resident, however only has worked on the neurosurgery ward for two weeks. Then there was Dr. Bezyan, who was an intern on her first day in the ward. Dr. Little's instruction after first seeing Vanessa was to chart and give Dilantin, this was not followed, even after the Concerns given by Mrs. Anderson about the side effects of Dilantin, this was not communicated. Dr. Ismail failures to recognize that Vanessa had been given Panadeine Forte. He also failed to refer Dr. Little in regard to upping analgesia. The let-down by medical staff to be aware of policies which require consultation with the treating Doctor in cases there is limitations that the quantity and type of analgesia should have been known, also they failed to do examinations as to the set time frames. The knowledge, though with good intentions in regard to privacy, of placing Vanessa in a room that was the furthest away from a …show more content…
Nurses station. No records of what may have been a important event at about 1 am on 8th November 2005. Carayon et al.
(2014, p. 14) due to poor communication it is one of the major problems in the medical field. This is a concern that has raised within the people working in the hospital and the common people. Poor communication has been shown an increase in death in hospitals. However, the common issue is delayed communication, which may lead to the lack of safety provided to the patients. In addition, Dekker (2016, p.44) states that the main problem in the communication systems in hospitals is among physicians. This is due to the ego among the professional people, this leads to the lack of care of the patients. This lack of communication blocks the advancement of the
diagnosis. For Vanessa Anderson, the coroner shows that the death happened due to miscommunication with the nurses. The nurses that were taking care of Vanessa gave her therapeutic dose of codeine four times and never provided her with any anti-convulsive drugs to prevent a seizure. The coroner also stated that the death was due to the occurrence of the seizure, not due to the golf ball that hit her (smh.com.au, 2016). Wu et al. (2013, p.723), the lack of communication between nurses and the lack of information about medications and the way they affect the health of patients. To try to prevent this, nurses need to be trained about various medications and their effects they can have. In regards to this, Singer and Vogus (2013, p.373) show that the hospitals need a chart that will outline the effects and usage of various medications. With Vanessa case, the lack of knowledge and miscommunication in nurses lead to this disaster. However, in this event it is essential all nurses maintain an up to date record book that is detailed of the events that happened to the patient, this requires time when a medication was admitted. This helps nurses when they have to work in shifts. The other way nurses can communicate batter is by using the clinical handover, which provides information to the next nurse of the patients (Mueller et al. 2012, p.1057). Registered nurses primary duty is to provide safety to the patients in their care and the hospital. They need to know of any activity that leads to deterioration of the health of the patients and be able to alert this activity that deteriorates the health of the patients (fiabane et al. 2013, p. 2016). It is a duty of care for the nurse to report this deterioration to right professional for the right treatment for the patients. According to Dubois et al. (2013, p.110) points out that patients safety should be the high priority of the nurses. To be able to achieve the success of nurses, the hospitals need to have a team that can respond to emergencies. The team will need to be able to avert the crisis and improve the deterioration signs. Kirsebom et al. (2013, p.886) shows that the hospital needs to develop an administrative structure that works with the team, this aim is to provide facilities, education, support and training to all nurses regarding to health deterioration, which will help with improving their communication (William et al. 2013, p.886). Shown in the report from the coroner, it is understood that Vanessa death happened due to miscommunication and lack of medication knowledge. The non-appearance of the hospital having guidelines that increase the likelihood of prescribing multiple medications without knowing the side effects that can happen. The amount of codeine in Vanessa's system led to respiratory problems. The absence of the team and nurses responsible also contributed to the deterioration of Vanessa health. The lack of knowledge about the different medicines and the antibiotics that contributed to the death. The lack of communication has played a huge role in the death of Vanessa. The nurse did not have an appropriate understanding of each other and this led to the high amount of medicine. Other influences are that the symptoms that later developed from the excess amount of medicine was not observed and properly reported by the nurses (The Australian, 2016). These are the main factors that led to the death of Vanessa. From the coroner's report, Vanessa death was solely by medical negligence. Williams et al. (2013, p.80) showed that it is important that patients safety is the most important factor that all hospitals need to commence. However, the staff at Royal North Shore Hospital all failed to provide the right treatment for Vanessa. She was admitted to a room that was not equipped for surveillance, thus, the nurses did not do their observations on Vanessa effectively and never wrote the notes. Nurses need to keep a record book that can help them keep up to date information about all patients. This also helps nurses and doctors to provide the right care and know what the right action of treatment. Hence, it can be concluded that communication is a high importance in all hospitals and that the lack of communication can impact the lives of patients and their families. Communication will reduce the gap between all hospital staff and help to understand between them all. The roles that nurses take on should be delegated that way they don't feel overburdened. It is a major importance that nurses maintain an up to date activities on their patients. this will help any misunderstanding of the diagnosis of any patient. Education is also another major role that nurses need to undertake to gain the right knowledge about medications. As negligence of the nurses led to Vanessa Anderson Death. The lack knowledge between the nurses and coordination between them led to a tragic that tainted Royal North Shore Hospital reputation. Thus, it's important that those flaws are identified that prevented the proper diagnosis of Vanessa. Medical flaws can be rectified so this does not happen to another family. The death of Vanessa Anderson at a very young age of 16 years was a tragic and a avoidable death. Vanessa's case should be used as a precedent to highlight how individual errors of judgment, failure to communicate, failure to record accurately and poor management of staff resources, cumulatively led to the worst possible outcome for Vanessa and her family
Communication is cited as a contributing factor in 70% of healthcare mistakes, leading to many initiatives across the healthcare settings to improve the way healthcare professionals communicate. (Kohn, 2000.)
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Carole noticed while in the tertiary care how the staff seemed to be overworked. She also felt that they did not talk to each other and when they did, she felt left out and her opinions were not considered. Her primary care physician was not informed of Carol’s progress, neither did she know about any post-stroke support. Physiotherapy waiting list was extremely long. On multiple occasions she could not tell her care providers about each other for fear of repercussions. This eventually led to two uncoordinated treatment plans, as they “were not funded” to talk to each other.
(3 nursing, 2015). Communication is one of the most important factors for working in the ambulance service, it provides knowledge and understanding, and it also allows you to connect with your patients and vice versa. Communication between health care works in paramount, anything can be misconstrued. Information that is not transmitted correctly the message is unclear and the message gets miss read, this could cause endless issues for staff and patents. Or sometimes things can be misinterpreted. This is when accidents can occur and my case study is based on lace of communication between staff and
The other problems are the modalities that the hospital should employ so as to resolve the issue. While experts are in agreement over the need to find a lasting solution to the problem, they are, however, far from getting a standard stand on how to approach the matter. The implication is that even if the management is to find a ground, it is likely to be a partially binding since some people will oppose it while others will support it. That is a variable that serves to complicate an already complicated
Communication encompasses a wide range of processes such as the exchange of information, listening, posing of questions (Fleischer et al., 2009) or use of body language. In a healthcare environment where there are constant interactions among nurses, doctors, patients and other health professionals, professional and effective communication is important in ensuring high quality healthcare standards and meeting the individual needs of patients.
Understanding that all patients needed to be treated justly and given the opportunity to make decisions in their care is important. Not causing harm and preventing them from harm is also the duty of health care workers. These ethical principles are essential to keep in mind with interdisciplinary communication. Ineffective communication has been associated with medical errors, patient harm, and increase length of stay. Failure to communicate properly has been associated with 79% of sentinel events (Dingley, Daugherty, Derieg & Persing, 2008). Good communication has been shown to improve patient satisfaction, increase in patient safety, as well as a decrease in health care costs (Paget et al.,
The problem of poor communication stems from an environment of high stress levels. After a consulting company scrutinized processes throughout the hospital related to care coordination and patient flow, the evidence was clear. The company identified areas for improvement around communication at many different levels. In order for patients to have a seamless transition from admission to discharge, the lines of communication needed to change. Daily face-to-face meetings were productive for the staff, hospital and overall satisfaction. The consulting firm worked for the hospital for several months, but as they departed, the prior culture of poor communication started to engulf...
In the provision of a high quality care, many factors influence the way it is provided; however, IC is crucial. A healthy work environment would result from open communication among the staff, it would increase the employees and patients’ level of satisfaction and sense of well-being. Good communication is the cornerstone for the IC, it is a complex process which requires to develop some skills to learn how to transmit some information. One of the most common factors leading to medical errors, are due to miscommunication, sometimes because the message is not clearly sent, and others because it is not clearly received or it is misunderstood (Danna, 2015). In terms of communication non-verbal communication must be taken into consideration as well; body language, facial expressions, use of space, and touch, entail conscious or unconscious movements and gestures, also impacts the communication among the staff and
On April 22, 2008, Anita passed after sustaining injuries she received from a domestic violence altercation. Despite the many trials in her life, she led a happy life and could always find humor in any situation. Always willing to lend a helping hand, one might consider her a natural caregiver. Happy, comedic, and a bit eccentric are words used to describe Anita. Her family would never could have imagined she would meet her tragic demise at such a young age. Oblivious to the abuse in their short and tumultuous relationship, no one was aware of her situation. She sustained injuries from a blunt force trauma during a domestic dispute with her boyfriend. Suffering from a horrific headache after the assault, her mother took her to the local hospital. The family received the disturbing call that would change the entire family dynamic. Anita was hospitalized due to injuries sustained from her boyfriend. She had reported the assault to the hospital employees, and then slipped into a coma (Desert Dispatch). Flown to a better equipped facility, neurological surgeons performed surgery in an attempt to salvage her life. The members of her family arrived at the facility not knowing what to expect. Life support machines breathing life into her, the family was distraught. The neurologist asked her sister’s to meet with him in the conference room. They knew what he would say, and devastation overtook them. Declining brain activity from one day to the next, the doctor stated that if she survived, she would awake into a vegetative state and require institutionalization. Anita’s family made a unanimous decision and did not want her to live without any quality of life. Immediately, family and friends showed up later and with heartach...
According to Boykin “Caring is the foundation of nursing” (Boykin et al, 2011), and it is the nurses’ responsibility to understand what it means to be caring toward patients, which can be achieved through having professional communication skills. Not only does not being able to communicate affect the patient, but also it affects how the nurse is able to do his or her job to the best they can. Smith and Pressman say that the Institute of Medicine has released reports, which stress, “good communication is critical to ensuring safe and reliable nursing” (Smith & Pressman, 2010). Bad communication skills have the potential to be more dangerous to the patient and can in tern make a life-threateni...
Despite the frequency of verbal interactions, miscommunication of patient information occurs that can lead to patient safety issues. . . . ‘Effective communication occurs when the expertise, skills, and unique perspectives of both nurses and physicians are integrated, resulting in an improvement in the quality of patient care’ (Lindeke & Sieckert, 200...
Communication involves relaying information from an individual to another through the use of verbal and nonverbal techniques. Many factors affect the effectiveness of information relay. It involves evaluating verbal aspects such as tone of voice, the emotional content being communicated, the timing and rapport of the interaction with patients, and nonverbal techniques such as facial expressions, time invested. It is necessary for productive and satisfactory work environment, improved patient outcomes, and settling conflicts. The purpose of this paper is to identify issues with ineffective communication and ways to improve proper communication throughout the a hospital’s interdisciplinary team and patients.
The aim of this essay is to explore the role of the health professional. This essay will look into the different team members that would be dispatched to the scene of the major incident. It will look into different concepts, such as ethical and moral dilemmas the professional may have to deal with. It will also look in to the professional qualities and values needed to practise in a specific field and explain how and why a professional body regulates practise and conduct for specific professions.
Ny resident, CG, who mentioned earlier was there for a hip fracture. I noticed her pain medication order was acetaminophen as needed. I mentioned this to the nurse who said that CG was complaining of pain because she was administered the acetaminophen too close to her therapy session. CG had been admitted earlier that week. This was her second therapy session.