May is a 40 year old female who was admitted to your ward post appendicectomy. The handover from the recovery staff is that all went well, there was minimal blood loss and she is a little drowsy still. The ward is busy and May’s first post operative observations are missed due to the nurse caring for other patients. The ward receptionist receives a phone call from May’s husband asking how she is, as he had a strange phone call from her and she did not appear to be making sense. The receptionist find the nurse caring for May and asks her to speak with the husband. The nurse reassures the husband that May is fine and she will go and check on her in a while. May’s husband insists on the nurse attending to his wife now. The nurse leaves her other patients and attends May, whom she find slumped in the bed unarousable. The nurse calls a MET call and May’s initial observations are: Respiratory Rate: 4 BP: 60/40 Pulse: 120 Temperature: 35.5
Question 1 – Looking at this case study, which of the mistake could have been prevented and why? Identify one mistake Identify current relevant legislation that is in place to prevent this mistake from happening, Evaluate the nurses role in this mistake and link it to the legislation used above Question 2 – Who is at fault for the observations not being undertaken on time? Identify who is at fault. Identify the reporting structures in place for the person at fault and why these are important What are the consequences of post operative observations not being undertaken according to the hospital policy? Argue your decision and refer to legislation Question 3 – Give 2 options available to nursing staff to escalate unsafe staffing levels Identify two options for nursing staff to escalate unsafe staffing levels If you were the nurse in charge on this shift, how would you ensure patient care was not put at risk despite low staffing ratios? Argue your decision and refer to legislation Reference List Please list in APA format all references used. Please note the indents used in APA are not transferable to PebblePad and it is therefore acceptable to not have an indent
SOLUTION
Question 1:
Identified Mistake: The mistake that could have been prevented is the failure to perform May’s first post-operative observations in a timely manner, which led to a delay in identifying her deteriorating condition.
Relevant Legislation: The relevant legislation to prevent this mistake is the Duty of Care principle under common law, which requires healthcare professionals to take reasonable care to avoid foreseeable harm to their patients.
Nurse’s Role: The nurse’s role in this mistake involves failing to prioritize May’s post-operative observations and respond promptly to her husband’s concerns. This breaches the Duty of Care principle, as the nurse did not fulfill her obligation to ensure May’s safety and well-being.
Question 2:
Fault for Missed Observations: The nurse responsible for May’s care is at fault for not conducting the post-operative observations on time.
Reporting Structures: The reporting structures in place for the nurse at fault include reporting to the nursing supervisor or manager, as well as documenting the incident in the patient’s medical record. These reporting mechanisms are important for accountability, quality improvement, and ensuring that appropriate actions are taken to prevent similar incidents in the future.
Consequences of Missed Observations: The consequences of post-operative observations not being undertaken according to hospital policy can include delayed detection of complications, deterioration in the patient’s condition, and potential harm or adverse outcomes for the patient. This could result in legal liability for the healthcare provider and breach of patient safety standards.
Question 3:
Options to Escalate Unsafe Staffing Levels:
- Notify Nursing Supervisor: Nursing staff can notify the nursing supervisor or manager about the unsafe staffing levels, providing specific details about the staffing shortage and its impact on patient care.
- Activate Chain of Command: Nursing staff can follow the established chain of command within the healthcare facility to escalate concerns about unsafe staffing levels, starting from the immediate supervisor and escalating to higher levels of management if necessary.
Ensuring Patient Care Despite Low Staffing Ratios:
As the nurse in charge on this shift, I would ensure patient care is not put at risk despite low staffing ratios by:
- Prioritizing Patient Care: Focusing on essential patient care tasks and allocating resources effectively to address immediate patient needs.
- Utilizing Available Resources: Mobilizing available resources, such as calling in additional staff, redistributing workload among team members, or utilizing agency staff if feasible and within policy.
- Communication: Maintaining open communication with team members to ensure awareness of patient care priorities and any concerns related to staffing levels.
- Documentation: Documenting any staffing-related issues, patient care interventions, and communication exchanges to ensure accountability and facilitate follow-up actions.
Legislation References:
Duty of Care Principle: Under common law, healthcare professionals owe a duty of care to their patients to take reasonable care to avoid foreseeable harm. This principle forms the basis of patient safety standards and legal obligations in healthcare practice.