The current case study is concerned with the failure to provide adequate treatment to Patient C, culminating in the Patient’s death on January 14, 2017. The cause of death was determined to be overwhelming sepsis as a result of Melioidosis in the Patient. But it is the quality of treatment or the lack thereof provided to Patient C in a remote hospital over several days prior to his admittance on January 10 2017, that is a major source of concern and is the primary subject of the present study. According to the complaint filed by the Patient’s family, the failure of remote hospital staff to accurately identify and investigate the reason for C’s deteriorating symptoms, which finally resulted in the Patient’s death, was the source of their worries. In the case of the disease Melioidosis, it is extremely difficult to detect the condition in children since youngsters do not exhibit any symptoms. There are three primary causes of negligence that can be observed in the case study. The first was a lack of documentation in the remote hospital because C first presented to the hospital on January 5 and continued to visit the hospital every day until January 10 on the day of his admission; there was no record until January 9. The second was a lack of documentation in the remote hospital because C first presented to the hospital on January 5 and continued to visit the hospital every day until January 10. As a result of making an early diagnosis based on common symptoms that were observed in the community, the doctor did not provide patient-centred care, which was the second reason. It was clinically inappropriate for C’s mother to express her continuous concern about him over the weekend because of the failure of nursing personnel at the distant hospital to review and document C’s status, which was the third reason.
The present report shows a lack of patient-centred care in remote hospitals. In the field of child care, the term “Family-Centred Care” refers to a partnership approach that encourages parents to be actively involved in their children’s upbringing and development (Coats et al., 2018). The Family-Clinic Collaboration (FCC) promotes dialogic dialogue between families and clinicians with the goal of improving the effectiveness, efficiency, and empathy of paediatric health care for children and adolescents (Richards et al., 2017). The nurse failed to implement the Children’s Early Warning Tool even Patient came to the care facility every day with worsening symptoms (Trubey et al., 2019). Despite the fact that the Patient’s parents took an active role in the treatment process, the nursing staff never showed a feeling of urgency when it came to giving the care itself. Further evidence of negligence may be found in the fact that the nursing staff failed to preserve a record of the Patient’s medical history from the initial visit. It was up to the nursing staff to advocate on the Patient’s behalf and on behalf of his or her family members because the doctor neglected to retain any notes of the Patient’s first two visits, which was their job under the circumstances. According to the Australian Health Practitioner Regulation Agency’s Registered Nurse Standards for Practice, “a nurse advocates on behalf of individuals in a way that respects the person’s autonomy and legal viewpoint” (Standard 2.5) (Ausmed, 2022). The nurse’s lack of concern for patient care was also immediately obvious because the mother attended the remote care facility on Saturdays and Sundays. In that cases, nurses may have checked the Patient’s condition and the mother’s fear, and if they had done so, they might have called for assistance from the doctors.
The capacity to advocate for patients builds the general nature of patient consideration; by the by, most of medical attendants are restricted in their capacity to play out this obligation. As indicated by studies, weakness, an absence of understanding in regulation and nursing morals, and a lacking help for medical attendants and doctors in administrative roles in emergency clinics are on the whole factors that add to the disappointment of nursing promoters to advocate for their patients. Principle premise recognized was a resistance between the medical care group, administration clients, and the wellbeing organization, that included health establishment and workplace, ineffectual correspondence and relational connections, patients’ families, and strict or social convictions. Optional subjects recognized were incapable correspondence and relational connections, patients’ families and strict or social convictions. An absence of coordination between the medical care staff, care beneficiaries, and the wellbeing organization was another subject that was taken note. Expanded issues and, at last, passing were the result of fruitless backing endeavors (Nsiah et al., 2019). Knowing how to appropriately document a patient might actually be the difference between life and death when it comes to nursing paperwork. It’s possible that some of the most prevalent medical record mistakes are also the most dangerous. Aside from that, incorrect paperwork may expose an employer to litigation and malpractice lawsuits. Healthcare personnel frequently fail to provide full clinical information in an accurate and timely way, despite the fact that good patient recording is widely considered as necessary for providing safe and ongoing municipal senior care. In primary care, accurate patient documentation is critical for assuring the quality of treatment, the continuity of care, and the safety of the Patient. The quality of nursing documentation has been criticised for many years due to a lack of consistency. This growing complexity in primary care nursing necessitates greater awareness of the need for and concentration on the provision of suitable nursing-supportive technologies, such as high-quality electronic patient records (EPRs), as the key tool for documenting practises in primary care nursing. Providers of adequate documentation of healthcare linked with the patients’ physical and mental health difficulties are especially crucial when dealing with senior patients since even slight changes in health status might be signs of serious or acute diseases (Bjerkan et al., 2021). By the phrase “missed nursing care,” which was coined in 2006, it is defined as “any portion of necessary patient care that is missing or delayed” (MNC). Nursing studies that looked at the factors that led to the formation of multinational corporations reached to the conclusion that a shortage of labour resources was the most frequently cited issue, followed by a lack of material resources and, lastly, a lack of communication. The most often cited concerns in labour resources included an unanticipated rise in patient volume and/or acuity, as well as a lack of sufficient numbers of personnel to handle the workload. In terms of materials resources, the most frequently reported issues included a lack of medication availability when it was needed, as well as a scarcity of supplies and equipment, while the most frequently reported issues in communication included poorly balanced patient assignments as well as a failure to maintain effective communication with medical staff (Hammad et al., 2021).
Sepsis is remains the greatest cause of mortality in children under the age of five, according to the Centers for Disease Control and Prevention. Approximately one-third of those who are impacted suffer from chronic, and in some cases irreversible, issues, resulting in a considerable rate of death and morbidity. The importance of a coordinated strategy to care is emphasised in the Australian National Action Plan for Sepses in order to address the devastating impact of sepsis on the health of children and adolescents is emphasised. The Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospitals; however, more attention should be paid to families, pre-hospital detection, and post-hospital care, which should include the multidisciplinary team, in order to improve patient outcomes, as outlined in the guidelines (Harley et al., 2021). Several healthcare systems throughout the world have created protocolised sepsis detection and treatment bundles for children in response to the Surviving Sepsis Campaign’s guidelines, with the goal of improving patient outcomes. It takes a lot of effort to successfully adopt clinical pathways, and the participation of registered nurses is essential to making it happen. Surviving Sepsis Campaign (SSC) advocates for the implementation of an asepsis regimen, along with the creation of a systematic screening tool to aid doctors in the early diagnosis and treatment of sepsis in children. It has been demonstrated to be beneficial for treating children with sepsis; however, several obstacles remain in the way of applying routes in clinical practise, leading in significant variations in treatment both nationally and globally (Harley, Schlapbach, Lister, et al., 2021).
As the present case indicated, lack of documentation and lack of Children’s Early Warning Tool application was a major factor for improper care to the Patient. Good clinical communication is made possible by accurate nursing documentation. Nurses’ evaluations, changes in clinical status, and patient information are accurately recorded inappropriate documentation, allowing the multidisciplinary team to offer excellent care while remaining organised. It is an important professional, and medico-legal necessity of nursing practice to document care since it serves as proof of services provided. Nurses are only human, after all. As a result, it’s reasonable that recurrent patients, who tend to clog the healthcare system with unrelenting grievances, would be looked at with a certain amount of frustration from time to time (Australian Commission on Safety and Quality in Health Care, 2019). Nonetheless, each and every Patient needs their undivided attention as well as the most suitable medical treatment. Nurses should avoid incriminating themselves in any inadequate application of treatment when recording any encounters with such patients in their medical records. It’s possible that one of these individuals may eventually appear with a real, life-threatening problem. Make certain that nurses do not play a role in ignoring or her concerns. In the field of registered nursing, documentation and record-keeping are essential components of the profession. The ability of diverse healthcare practitioners to communicate with one another is critical to the quality and coordination of client treatment. Documentation is a type of communication that allows registered nurses and other healthcare professionals to communicate information regarding a client’s treatment. However you choose to document, documentation and the client record are official, legal records that provide information about a client’s healthcare and development. A quality documentation system includes all contact with family or other vital supports as well as any health education or psychiatric support that is provided. It also includes the technique used to get informed consent as well as the identification of the completed consent forms. High-quality documentation includes both discharge planning and discharge information, which are two components of the documentation process. This should include information on the client’s condition at the time of release, any self-care training or education that was provided, and any follow-up visits or referrals that were scheduled. Documentation, which includes the quality of telephone health advice provided to consumers, is also a critical component of providing high-quality service to customers (Nabwami, 2018).
Conclusion
The current case study is concerned with the failure to offer enough care to Patient C, which resulted in the Patient’s death on January 14, 2017, as a result of the failure to provide adequate therapy. Even though the Patient came to the care facility on a regular basis with deteriorating symptoms, the nurse neglected to utilise the Children’s Early Warning Tool. Despite the fact that the Patient’s parents were actively involved in the treatment process, the nursing staff never showed a sense of urgency when it came to providing the actual care. A further instance of carelessness may be discovered in the fact that the nursing staff neglected to keep a record of the Patient’s medical history from the Patient’s first visit to the facility. Because the doctor failed to keep any notes from the Patient’s first two visits, which was their responsibility under the circumstances, it was up to the nursing staff to advocate on his or her behalf and on behalf of the Patient’s family members, which they did successfully. A quality documentation system includes all contact with family or other vital supports as well as any health education or psychiatric support that is provided. It also includes the technique used to get informed consent as well as the identification of the completed consent forms. High-quality documentation includes both discharge planning and discharge information, which are two components of the documentation process. This should include information on the client’s condition at the time of release, any self-care training or education that was provided, and any follow-up visits or referrals that were scheduled. Additionally, including customer-provided telephone health advice in the quality documentation is a crucial component of providing high-quality service.
References
Ausmed. (2022). What is Patient Advocacy? | Ausmed. Www.ausmed.com. https://www.ausmed.com/cpd/lecture/patient-advocacy
Australian Commission on Safety and Quality in Health Care. (2019). Documentation of information. Safetyandquality.gov.au. https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/documentation-information
Bjerkan, J., Valderaune, V., & Olsen, R. M. (2021). Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students. Frontiers in Computer Science, 3. https://doi.org/10.3389/fcomp.2021.624555
Coats, H., Bourget, E., Starks, H., Lindhorst, T., Saiki-Craighill, S., Curtis, J. R., Hays, R., & Doorenbos, A. (2018). Nurses’ Reflections on Benefits and Challenges of Implementing Family-Centered Care in Pediatric Intensive Care Units. American Journal of Critical Care, 27(1), 52–58. https://doi.org/10.4037/ajcc2018353
Hammad, M., Guirguis, W., & Mosallam, R. (2021). Missed nursing care, non-nursing tasks, staffing adequacy, and job satisfaction among nurses in a teaching hospital in Egypt. Journal of the Egyptian Public Health Association, 96(1). https://doi.org/10.1186/s42506-021-00083-0
Harley, A., Schlapbach, L. J., Johnston, A. N. B., & Massey, D. (2021). Challenges in the recognition and management of paediatric sepsis — The journey. Australasian Emergency Care. https://doi.org/10.1016/j.auec.2021.03.006
Harley, A., Schlapbach, L. J., Lister, P., Massey, D., Gilholm, P., & Johnston, A. N. B. (2021). Knowledge translation following the implementation of a state-wide Paediatric Sepsis Pathway in the emergency department- a multi-centre survey study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07128-2
Nabwami, L. (2018, May 27). Record Keeping and Documentation. Ausmed.com. https://www.ausmed.com/cpd/articles/record-keeping-documentation
Nsiah, C., Siakwa, M., & Ninnoni, J. P. K. (2019). Barriers to practicing patient advocacy in healthcare setting. Nursing Open, 7(2), 650–659. https://doi.org/10.1002/nop2.436
Richards, C. A., Starks, H., O?Connor, M. R., & Doorenbos, A. Z. (2017). Elements of Family-Centered Care in the Pediatric Intensive Care Unit. Journal of Hospice & Palliative Nursing, 19(3), 238–246. https://doi.org/10.1097/njh.0000000000000335
Trubey, R., Huang, C., Lugg-Widger, F. V., Hood, K., Allen, D., Edwards, D., Lacy, D., Lloyd, A., Mann, M., Mason, B., Oliver, A., Roland, D., Sefton, G., Skone, R., Thomas-Jones, E., Tume, L. N., & Powell, C. (2019). Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review. BMJ Open, 9(5), e022105. https://doi.org/10.1136/bmjopen-2018-022105
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