Clinical Incident: Case Study Analysis And Lessons Learned

What happened in this clinical incident?

The clinical incident ultimately caused the death of the patient A, who was 81 years old. Since the time she first visited on 6^th January, 2013 she complained about shortness of breath and dizziness. She was first prescribed oral Lasix. She came back again on 6^th January and stated that oral Lasix had not provided any amount of relief to her.  She was then admitted to the hospital on that day. On 9^th of January, she reported feeling extremely weak and dizzy and she even refused her meals. Patient A also reported an intense abdominal pain. Her reports revealed an increased heart beat that coincided with atrial fibrillation. On January 10^th, the VMO assessed the patient with depression and anxiety and prescribed mobilization of the patient by the enrolled nurses. Further, patient A complained about having severe abdominal ache and nausea. She even informed about having severe back pain that restricted her ability to move. At this critical situation her reports revealed, an increase in her WBC count, development of an urinary infection and serious medical illness as on 11^th January. She had only been administered Digoxin and Valium to control her heart beat and intravenous antibiotics till this point of time. Registered nurse John then took over the duty and followed an extremely careless approach towards patient A. On being informed repeatedly about the seriousness of the worsening medical condition of patient A, he took no action to tackle the seriousness. Patient A developed persistent diarrhea and despite the enrolled nurse informing him about the critical condition, RN John was rigid about the fact that he would only review the patient once the locum arrives. Although, he advised for an ECG and access the patient before the locum arrived, but he did not record any observations and it appears that the ECG at this point was unnecessary. He further telephoned the clinical nurse manager, Ms. Sophie Smith to deliver some medications for another patient and did not seek any medication about patient A or inform anything about the criticality of patient A. Before the VMO arrived he filled up the ISBAR form where he mentioned patient A to be critical and that her family had already been contacted. Finally, the VMO arrived and inserted a large bore IV cannula to treat the dehydration and recommended immediate transfer of the patient to referral but by then the patient had deteriorated considerably and eventually died. 

What can we learn from this case study about our own preparedness for professional practice?

The major fault that can be traced according to the proceedings of the case study is the irresponsible and laid-back professional approach of the registered nurse John. On being repeatedly informed by the enrolled nursing professionals who were in charge of taking care of patient A, about her deteriorating condition and diarrhea, he should have immediately reviewed the patient at that point of time and documented the minutes of the observation (Thompson et al., 2013). Further, conducting an ECG at that point of time when already the progress notes stated a high heart rate of 88, low blood pressure and a respiratory rate of 40-44/min and feelings of dizziness. As a registered nurse he should have immediately telephoned the clinical manager and asked for medication for patient A and explained the seriousness of the situation to her (Tiffen et al., 2014). As a responsible nurse he should have reviewed the patient thoroughly and documented the observations so as to immediately deliver it to the clinical manager on her arrival so that she could contact the VMO and discuss the further intervention. It is important for the nursing professionals to be extremely alert and maintain a proactive attitude while dealing with patients (Standing, 2017). This proactive approach helps avoid delay in devising further interventions and also addresses the seriousness spontaneously (Riegel et al., 2013). Proper communication could help in arranging for the transportation to the referral faster and it would have perhaps saved the life of patient A (Shaban, 2015). RN John on being informed about the patient’s continual diarrhea should have immediately administered medication to help the patient with severe dehydration and provide some relief. As a nurse or a midwife, the most important elements that should never be compromised with while delivering service delivery is to document every minute observation and communicate (Paterson et al., 2016). This helps in avoiding medical errors to the maximum. It should also be critically noted here that the progress notes that were handed over to John should have clearly stated the recent administration of antibiotic and the possibility of profuse diarrhea as a side-effect. Also, it is important to notice that while devising interventions or medications an interaction or consent of the patient was not taken. This is a crucial aspect as excluding it can lead to a number of issues such as prescribing wrong medications that the patient might be allergic to and the less or no participation of the patient often leads to demoralizing the patient and causes stress and anxiety. 

How many contributory factors are we expected to use?

Change in professional behaviors such as maintenance of a proactive and alert attitude while dealing with patients can help in avoiding such scenarios. In addition to this, evidences reveal that nursing practice involves the art of being able to prioritize patients and proceedings (Abbott et al., 2013). For instance, registered nurse John could have easily prioritized the critical condition of patient A and conveyed the same to the registered clinical nurse and asked for immediate medication to treat dehydration. This could have helped in speeding up the process of recovery. The flow of communication is an important aspect in nursing and it must be acknowledged that the life of a patient is dependent upon this particular professional aspect (Cerit & Dinc, 2013). Efficient team work and the ability of nurses to quickly take a decision based on the series of clinical events and making use of their clinical knowledge can help in avoiding scenarios of inefficient treatment (Hoffmann et al., 2014). The spontaneous decision making ability also helps in avoiding delay while devising interventions or treating critical patients (Legare & Wittemann, 2013). 

On closely evaluating the case study I could identify that I am still to learn a lot in terms of experience so as to avoid such medical errors. I could identify three key aspects that govern an efficient nursing practice and the three elements are better decision making ability, better flow of communication and being alert and spontaneous while dispensing medical service delivery. According to me, I would be able to enhance my preparedness for professional practice by stringently following an action plan that I have chalked out for myself. The action plan created by me involves activities that efficiently cover all the three fundamental aspects that are required in order to deliver zero error and perfect service delivery. In order to improvise my skills on decision making, I have decided to work in close association with my supervisors so as to understand the key elements that help them in urgent and critical decision making. I believe working with my superiors would also help me gain experience on closely observing the procedure they following while handling medical emergency cases. This would not only be based on following their practice but would also be based upon their experience over time. I believe on stringently adhering to these principles I will be able to prepare myself in a better way. This would significantly help me in dealing with any critical or non-critical cases and help me avoid any incidence of drug error or professional casualty.  

References:

Abbott, P., Mc Sherry, R., & Simmons, M. (Eds.). (2013). Evidence-informed nursing: A guide for clinical nurses. Routledge.

Cerit, B., & Dinç, L. (2013). Ethical decision-making and professional behaviour among nurses: a correlational study. Nursing ethics, 20(2), 200-212.

Hoffmann, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Jama, 312(13), 1295-1296.

Légaré, F., & Witteman, H. O. (2013). Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health affairs, 32(2), 276-284.

Paterson, B., Thorne, S., & Russell, C. (2016). Disease-specific influences on meaning and significance in self-care decision-making in chronic illness. Canadian Journal of Nursing Research Archive, 34(3).

Riegel, B., Dickson, V. V., & Topaz, M. (2013). Qualitative analysis of naturalistic decision making in adults with chronic heart failure. Nursing research, 62(2), 91-98.

Shaban, R. (2015). Theories of clinical judgment and decision-making: A review of the theoretical literature. Australasian Journal of Paramedicine, 3(1).

Standing, M. (2017). Clinical Judgement and Decision Making in Nursing. Learning Matters.

Thompson, C., Aitken, L., Doran, D., & Dowding, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50(12), 1720-1726.

Tiffen, J., Corbridge, S. J., & Slimmer, L. (2014). Enhancing clinical decision making: development of a contiguous definition and conceptual framework. Journal of professional nursing, 30(5), 399-405.