NUR3020 Professional Transitions

The assignment involves the case study analysis of the report of the Inquest into the death of Julienne Maria McKay-Hall who died on May 19, 2008 at the age of 46. The reason for death was reported to be complications following cardio respiratory arrest in association with an air embolism. This case study poses serious questions of patient safety, tort of negligence and ethical issues as these parameters led to the death of Mrs. McKay-Hall.

Assignment section one: Patient safety

In the nursing care for Mrs McKay-Hall’s care, registered nurses and enrolled nurses were involved in the chain of events transpiring to and foreshadowed chain of events leading to deterioration and deaths of the patient. In this coroner inquest, there were issues related to patient safety, patient care, communication, knowledge, accountability, reporting, responsibility and delegations that led to the deteriorating conditions and death of the patient.

In the case study, the deceased underwent laparoscopic sleeve gastrectomy surgery in St John of God Hospital on 9^th November 2007 and it was noted that while using staple guns, the firing was not proper and one of the staples did not fire properly resulting in leak from the staple line. After this, the deceased became ill and suffered from sepsis. Dr Hairul Ahmad performed the operation in consultation with the deceased as he had performed 15 surgeries earlier. Despite of the fact that there are high chances of risk in this surgery, the doctor did not check for the leak identification in the misfiring circumstances using methylene blue.

Post-operative care

After the surgery, the deceased was brought to the ward at 3pm on 9^th November 2007. According to the Frequent Observations Chart, the vital signs were recorded that were within normal range until 10:45 pm on 10^th November 2007. There was elevation in cardiac rhythm, oxygen saturation levels and blood pressure that dropped to 83%. Again, at 2:45 am there was still rise in blood pressure levels with normal cardiac rate and oxygen saturation levels. At 4:45 am, cardiac rate was still elevated with high respiratory rate and deceased was sweating profusely (++) that indicated leakage was severely infected and showed early signs of sepsis. After this, Nurse Laja completed an entry in Integrated Progress Notes at 5:30 am on 11^th November 2007. At this point, the deceased complained of shoulder tip pain (+++) and morphine was administered. Green fluid was also found that confirmed that stomach leakage was infected as it was bile leak.

Shoulder tip pain can result from blood or stomach contents fluid in the abdominal cavity irritating the underside of diaphragm resulting in pain. Even the deceased older sister confirmed that she was panting, disturbed and halted speech while talking on phone and still there was no proper reporting and documentation of the deceased abnormal state. The patient was hyperventilating and still the enrolled nurse did not escalate this issue to the doctor. According to Nursing and Midwifery Board of Australia (NMBA), documentation is critical part of patient care required for monitoring of clients and communicate well in the delivery of care (Standard of practice, Nursing and midwifery board of Australia”, 2017). They are held accountable for their documentation meeting the standard practice of nursing (Nursing and Midwifery Board of Australia – Registered nurse standards for practice”, 2017). According to NMBA, incident reporting is also important for patient safety and quality of healthcare that is related to incident reporting, information management and event analysis while coordinating with colleagues and seniors (Anderson et al., 2013).

The enrolled nurse should have consulted and reported the abnormal readings at that time only with the nurse coordinator. There was no entry in the Integrated Progress Notes about the abnormal vital signs that was important to know that conditions have improved or getting worse and required action considering the signs. On 11^th November 2007, another registered nurse, Jodi Windram also noticed that pulse rate of the deceased was elevated and stayed from that time. However, there was no Medical Emergency Team (MET) call made by the nurse. At St John of God Hospital, to make a calling criterion, an emergency number of 55 needs to be called at such events and pulse rate of 130 satisfied the criteria. She did not make a MET call justifying that elevated pulse rate due to the overall condition of the patient and did not require any emergency call. According to the Professional Code of Conduct in NMBA, nurses should practice in a competent nursing environment without compromising the safety of the patients under their provision of care (Blegen et al., 2011). By not making the MET call, it is evident that the nurse put the life of the deceased into danger compromising the safety.

Communication is another failure that led to the deterioration of the patient and eventually death (Brock et al., 2013). In the events when the nurse observed abnormal vital signs in the patient, she should have informed and reported the observations to the senior shift regarding the changes. During handover, the nurse should have advised the next nursing shift those abnormal vital signs should be communicated to the nurse coordinator as effective communication facilitates coordination of care (Mayor, Bangerter & Aribot, 2012). When the observations showed abnormality in vital signs, next observations duration should have decreased with effective communication between the nursing staffs until routine examinations resumed. There was no proper communication between the nurse and deceased as she showed halted speech, panted and could not hold her breath for long.

Delegation of care and accountability was also violated in this inquest case. During handover, the nurses should have informed about abnormal vital readings to the next nursing shift that they did not perform and held responsible for their own actions while delegating aspects of care. Moreover, there was no proper documentation in the notes that can be reviewed during delegation of care. From the above circumstances outlined, it is clear that nursing staff was incompetent while delivering adequate care and treatment to the patient. Several instances showed that she began to get sepsis from the leakage, however, until 12^th December 2007, 8 pm when the deceased was close to death.

At the St John of God Hospital, in 2007 a policy was introduced that supported timely and effective care of all patients, named Medical Review-Process for Seeking Prompt Review. The policy was developed to ensure that medical practitioner of the patient should be contacted prior making a MET call, blue bell or dial 55 emergency number. This incidence was violation of nursing responsibility, accountability and proper reporting in nursing care that led to the death of the patient, Mrs. McKay-Hall.

Assignment section two: the tort of Negligence

The doctors and nurses involved in the case of the deceased were handed to the regulating authority and a potential civil case could be filed against them. Conditions of negligence are witnessed in this case outlining the instances of nursing care by registered nurses and doctors.

During the 11th November 2007, Registered nurse, Jodi Windram was assigned for the evening or night shift. She checked for the deceased pulse and it was elevated 130 bpm. After knowing the abnormal vital signs of the patient, it was mandatory for the nurse to call the emergency number “55” as 130 bpm satisfied the calling criteria. However, she did not make an MET call and assumed that overall condition deterioration should have been the reason for making that call.

In this case, there is nursing malpractice as the nurses in charge did not fulfil their duties proving that they are not competent in providing care to the deceased. As nurses are the frontline of patient, it is the duty of a nurse to monitor patient’s condition. If they notice anything concerning, it is their moral duty to inform and if no so, the nurse may be liable for tort of negligence and malpractice for not notifying the higher authority (Heaton, 2014). In an instance, when the nurse found elevated pulse rate, she should have consulted with the nurse coordinator, there rises level of negligence. The new RN during her shift also found out that pulse was still elevated; she did not make ET call or raised any concern as a duty to report in nursing practice posing toort of negligence.

To be fair, Nurse Windram did contact Dr Ahmad to inform about the elevated 130 bpm pulse rate. However, Dr Ahmad did not turn up to see the patient and nursing staff assumed that doctor was aware of the situation and problem was due to Timentim that he made. This also implies doctor’s incompetence to perform his duty. After the operation, next morning, the doctor did not review the deceased saying that patient was fine and only had shoulder tip pain and abdominal wall tenderness that confirmed stomach leakage and suffered from sepsis. This is breach of duty of care on the part of Dr Ahmad that is liable for negligence in this case caused the deceased to suffer (Bishop, Ryan & Casalino, 2011).  

Improper documentation is also a serious accusation of negligence. It is the duty of a healthcare professional to document accurately about the patient’s condition for appropriate actions. In this case scenario, when the deceased condition proved stomach leakage and sepsis with hyperventilation condition, Dr Ahmad wrote observations in the Integrated Progress Notes as stable just below the entry made by Nurse Laja that was inaccurate and liable for tort of negligence. The doctor owes the duty towards the patient and negligent action in this tort had led to the deterioration and unnatural death of the patient (Austin, 2011).

In another instance, on the night shift of 11-12 November 2007, RN Gloria Kuyper took observations of the patient that showed high respiration and pulse rate. Despite of the fact, vital signs showed abnormal readings, the nurse did not increase the frequency of observations and failure to initiate MET response or call Dr Ahmad. This also claims for negligence in the breach of duty of care as nurses should practice nursing where they have the obligation to report a misconduct or concern to the higher authority safeguarding people under their provision of care (Nettina, Msn & Nettina, 2013).

Assignment section three: Ethical issues

The actions of the registered nurses and enrolled nurse involved in this case pose ethical considerations in the patient care. The nurses did not work in accordance with the ethical principles of non-maleficence, truthfulness and justice. Under the value statement 1 of NMBA Code of Ethics, nurses should demonstrate quality nursing care accepting accountability for standard of care and taking appropriate actions on reasonable grounds (Code of Ethics for Nurses in Australia, 2017). In the case scenario, RN did not report (MET call or contact doctor) the abnormal vital signs of the patient where they were questionable and showed unethical behavior. Nurses should also demonstrate a culture of safety where they need to understand the crucial importance of safety in the provision of care (Weaver et al., 2013). However, the nurses did not practice safe nursing care and failure to report or understand the crucial importance of the patient’s condition led to the death of McKay-Hall. Despite of knowing the impact of abnormal vital signs of the patient, they did not report to reduce the incidence of the adverse event leading to deterioration and eventually death of the patient.

The ethical principle of beneficence and non-maleficence are also violated in the given case. There is negligence, dereliction of duty and breach of duty of care by the nursing staff in post-operative care that led to the deterioration of the patient’s condition. Nurses did not make any emergency call or contacted doctor when the vital signs of the patient seemed abnormal that put her life into danger intentionally violating the ethical principle of non-maleficence (Johnstone, 2015). Beneficence states that a nursing act should benefit others by removing or preventing harms in order to improve others condition (Butts & Rich, 2012). However, in this case, despite of the fact that abnormal vital sign readings post surgery indicated stomach leakage and sepsis, RNs and enrolled nurses did not take any action that could have minimized the risk or made condition controllable. The abnormal readings revealed worsening conditions of the patient; nevertheless, the nurses were negligent and intentionally harmed and led to the death of McKay-Hall.

References:

Anderson, J.E., Kodate, N., Walters, R. and Dodds, A., 2013. Can incident reporting improve safety? Healthcare practitioners’ views of the effectiveness of incident reporting. International journal for quality in health care, 25(2), pp.141-150. Doi: https://doi.org/10.1093/intqhc/mzs081

Austin, S. (2011). Stay out of court with proper documentation. Nursing2016, 41(4), 24-29. doi: 10.1097/01.NURSE.0000395202.86451.d4

Bishop, T. F., Ryan, A. M., & Casalino, L. P. (2011). Paid malpractice claims for adverse events in inpatient and outpatient settings. Jama, 305(23), 2427-2431. doi:10.1001/jama.2011.813

Blegen, M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Medical care, 49(4), 406-414. Doi: 10.1097/MLR.0b013e318202e129

Brock, D., Abu-Rish, E., Chiu, C.R., Hammer, D., Wilson, S., Vorvick, L., Blondon, K., Schaad, D., Liner, D. and Zierler, B., 2013. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf, 22(5), pp.414-423. Doi: https://dx.doi.org/10.1136/bmjqs-2012-000952

Butts, J. B., & Rich, K. L. (2012). Nursing ethics, pp. 99-105, Jones & Bartlett Publishers. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=9R_ET0JLvEwC&oi=fnd&pg=PR5&dq=violation+of+ethical+principles+nursing&ots=faDbHUcs5E&sig=7t6Km-R6Mq1OUlseIVPqmE_oMx0#v=onepage&q=violation%20of%20ethical%20principles%20nursing&f=false     

Code of Ethics for Nurses in Australia. (2017). 5_New-Code-of-Ethics-for-Nurses-. Retrieved 11 December 2017, from https://file:///C:/Users/user00/Downloads/5_New-Code-of-Ethics-for-Nurses-August-2008%20(3).PDF

Heaton, L. (2014). Legal aspects of nursing. Kozier & Erb’s Fundamentals of Nursing Australian Edition, 3, 57. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=wMWaBQAAQBAJ&oi=fnd&pg=PA57&dq=tort+of+negligence+nursing+australia&ots=FEj7iG80ko&sig=1xr7i6D_BlJ8UX8BYcwlpNEwrok#v=onepage&q=tort%20of%20negligence%20nursing%20australia&f=false

Johnstone, M. J. (2015). Bioethics: a nursing perspective, pp. 1-12, Elsevier Health Sciences. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=4dRQCgAAQBAJ&oi=fnd&pg=PP1&dq=violation+of+ethical+principles+nursing&ots=YEtGRYyKji&sig=4hLwzWNXcKZyqcNFKPYiTeQsxvc#v=onepage&q=violation%20of%20ethical%20principles%20nursing&f=false   

Mayor, E., Bangerter, A., & Aribot, M. (2012). Task uncertainty and communication during nursing shift handovers. Journal of advanced nursing, 68(9), 1956-1966. DOI: 10.1111/j.1365-2648.2011.05880.x

Nettina, S. M., Msn, A. B., & Nettina, S. M. (2013). Lippincott manual of nursing practice, pp. 110, Lippincott Williams & Wilkins. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=yW8DhPxxUR0C&oi=fnd&pg=PR1&dq=breach+of+duty+of+care+in+nursing&ots=9O3VqiHnDv&sig=KRVfFNgNDFEIwdGcg2tdpxMXauM#v=onepage&q=breach%20of%20duty%20of%20care%20in%20nursing&f=false

Nursing and Midwifery Board of Australia – Registered nurse standards for practice. (2017). Nursingmidwiferyboard.gov.au. Retrieved 11 December 2017, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Standard of practice, Nursing and midwifery board of Australia. (2017), Retrieved 11 December 2017, from https://file:///C:/Users/user00/Downloads/1798150_1830561517_Nursing-and-Midwifery-Board—.PDF

Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a Culture of Safety as a Patient Safety StrategyA Systematic Review. Annals of internal medicine, 158(5_Part_2), 369-374. Doi: 10.7326/0003-4819-158-5-201303051-00002