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Breached Standards

Mrs. Betty White, an 85 years old woman was brought to the Emergency Department (ED) due to high temperature, shortness in breath and chest congestion. Betty was detected with pneumonia through preliminary tests such as X- ray of chest and blood report. She was assisted with intravenous (IV) antibiotics, oxygen and ventolin therapy with normal saline nebulisers. For further treatment she was shifted to respiratory medical ward with 4 beds and quite far from the nurse service station. Betty’s daughter Jane was there throughout the shift and before leaving for home she enquired the nurse in charge whether her mother was provided with the daily medicines as she had a history of hypertension, hypercholesterolemia, asthma and osteoarthritis. The nursing staff found that the details of the usual medications were missing from the medication chart and requested the doctor in charge to write the medicines. Jane before leaving for home had left her details and had asked the nurse to take proper care of her mother as she looked a bit confused than other normal days and in case of any emergency she should be informed. Following that night, Betty looked more confused and at one occasion she started calling her daughter’s name which was reoriented by the nursing staff after which the staff left for other patients. At 2 am, the nursing staff answered a call bell from one of the patient in Betty’s room who was shouting for help. The nurse found Betty lying on the floor and blood all over the floor as her IV was pulled out. Examining her, it was found that her forehead and legs were lacerated with foot being disoriented and uncontrolled urine in the floor. X-ray result as suggested by the medical officer showed intracapsular fracture of her right neck femur and was scheduled to orthopedic team. Post to 4 days after the surgery of her hip and right femur showed infection around the wound edges. All these incidents led to the concerned issues in clinical practices. At first Jane warned about the disoriented nature of her mother to the nursing staff before leaving, but they overlooked it (Digby & Bloomer, 2014). Patients when gets disoriented, it is required to conduct a screening test to understand the cause underlying the disoriented or confused state and immediately inform the doctor in charge (Faull & Blankley, 2015). In case of Betty, she should have been shifted to a ward close to the nursing station so that proper watch can be kept on her all the time (Carpman & Grant, 2016). A full time nurse should have been allocated to Betty as she was old with previous history of hypercholesterolemia that can result to incontinent urine. The nurses should have provided her a single room with quite environment. When they found Betty asking for her daughter they should have informed her daughter and let her talk to her mother. Proper hygiene should have been maintained in handling her as after the surgery she developed infection in her hip wound edges that made her feel more pained and stressed out (Anderson et al., 2014). Therefore, lack of communication and interest towards Betty’s condition led to severe issue of concern.

Preventing Infections

Some of the National Safety and Quality Health Service Standards as proposed by the Australian Commission on Safety and Quality in Health Care were not followed accordingly during Betty’s treatment. The first standard which was breached is Governance for Safety and Quality in Heath Service Organizations. The Australian commission suggests implementation of government systems for monitoring and improving the organization’s performance in patient experience (Goldberg et al., 2013).  They should improvise patient outcomes. This was not followed post Betty’s admission.  She was kept far away from the vigilance of nursing station her safety was not recognized. The second standard breached was Partnering with Consumers that explains the designing of health care system based on the requirement of patient. This too not maintained. Despite her old age, osteoarthritis, disoriented nature and incontinent urine tendency, a full time nurse was not allotted. There was no partnership between the consumer and the health organization following the Australian standard. The third breached standard was Preventing and Controlling Healthcare Associated Infections. The safety standard module focuses on strategies to prevent health associated infections and their antimicrobial management. Failure to meet this standard led to infection in the wounded hip post surgery (LaRussa, 2012).  The fourth Medication Safety standard as proposed by the Australian commission involves appropriate administration of medicines. Betty’s medical history was not recorded and there was lack of communication. The Patient Identification and Procedure Matching standard was also breached. It includes the identification of correct treatment plan and matching them to intended treatment. When Betty was disoriented and confused, the nursing staff should have conducted a screening test to understand her unusual behavior. The next standard is the Clinical Handover that includes the systems for timely and relevant transfer of patient based on the situation, which was not maintained due to miscommunication between patient and nurse, her daily medications was not recorded and was skipped for that day and in spite of her confused nature she was not referred to a suitable ward (Smeulers et al., 2012). Recognizing and Responding to Clinical Deterioration in Acute Health Care is the next standard that explains procedures implemented when the condition of the patient deteriorates.  It was breached because Betty’s daughter had already alerted the nurse about her mother’s confused state and in emergency to contact her. However, the nurse overlooked it and this led to Betty’s fall  from bed causing severe injury to her head, hip and foot with excess blood flow. The last Australian standard breached was Preventing Falls and Harm from Falls that implies the system to reduce the event of falls and the best management to incorporate if any falls occur. This was overlooked due to lack of proper management. (Dixon-Woods, McNicol & Martin, 2012). Betty was kept far away from nursing station, the nursing staff could not monitor her all the time and this led to patient fall from bed with excess blood flow and injuries on head and right leg with disoriented foot. X-ray report showed intracapsular fracture in her right neck of femur and was scheduled for surgery. She also developed infection post surgery (Anderson et al., 2014).

Preventing Falls and Harm from Falls

Preventing and Controlling Healthcare Associated Infections was one of the standards set up by the Australian safety and healthcare commission, which not maintained in Betty’s nursing care. It focuses on preventing of the patients from acquiring infections during hospital stay and effective manage (Anderson et al., 2014). During Betty’s stay in the hospital she had a fall from the bed and got an intracapsular fracture in femur. She underwent a surgery of the fractured femur and insertion of screw in hip area. After 4 days of her surgery the nursing staff found an appearance of infection with distinct smell around the wounded edges of the hip. The people during their hospital stay are prone to infection if they are sick or underwent a surgery. The surgical procedure plays an impact on the development of the infection in the surgical site.  The infection occurred post surgery in the area where the surgery is carried out (Rasouli et al., 2014). Thus, in order to control the prevalence of infection some strict policies should have been followed in Betty’s nursing care. Infection in the surgical site is one of the major kinds of challenge in the health care nursing. As Betty was undergoing an orthopedic surgery, the nursing department with the recommendation of doctor should have conducted a nasal screening test in order to identify any sensitivity of methicillin (Calfee et al., 2014). If the test showed positive result, a decolonization treatment showed have been done twice before the start of the surgery. The second recommendation was proper enquiry of previous history of smoking. Smokers have high risk of developing infections than the non smokers with delayed healing of the complicated infections (Soni et al., 2014). Smokers have the tendency to develop respiratory problems such as pneumonia which are already been detected in Betty. If the nurses have enquired about her smoking history, there was a chance to prevent the complications as she used to smoke. The third precaution is the proper hygiene of the hand. The hand should be washed properly after having meals and after using the toilet. The wounded region should not be touched with bare hands. The body temperature should be maintained by keeping the body warm throughout the procedure of surgery. Feeling of any kind of coldness in the body temperature should be informed to the staff in charge. The skin should be properly washed and cleaned before the surgery. The dressing of the wound must be kept as it is for minimum 48 hours post surgery. If required to change the dressing, it should be treated with clean procedures. The health care worker should remember to clean their hands properly after the completion of the dressing. Proper monitoring should be done in order to prevent the exposure of wound to outsiders. The nurse in charge should always maintain a routine checkup in order to report any kind of swelling with redness and pain in that wounded area (Weber & Kelley, 2013). If these precautions were maintained and monitored properly in the nursing of Betty’s injury; it could have been possible to strategically prevent the occurrence of infection in the edges of wounded hip after surgery.

Another National Safety and Quality Standard that was overlooked was prevention of falls and harm from such falls. Clinicians try to prevent falls that can lead to grave consequences in the patient. Falls are prevalent in people from all age groups. The harms depends on factors like muscle strength, balance, bone density and eye sight. This standard does not address any psychological or physical issues. Hospitalizations related to falls and old age show a steady increase. It has many social implications and affects the independence of the person (Ganz et al., 2013). The affected individual becomes a burden on the family as well. Certain guidelines have been proposed by the Australian Commission on Safety and Quality in Health Care for prevention of any untoward incident which leads to fall in older people in community care centers or hospitals (Gray-Miceli, Mazzia & Crane, 2017). One major implication of such fall is it leads to impaired locomotion in the patient. A similar incident occurred in the case study where Betty suffered fractures in the right neck of femur and hip. Proper governance is required to reduce incidence of such falls. The nurse-in-charge did not provide necessary care to Betty even when the latter’s daughter had advised her to do so. Some of the criteria that need to be followed in such a case include implementation of review policies and protocols that are consistent with practice guidelines, incorporation of screening tools and their regular monitoring. Clinical and administrative data should be used to investigate the frequency and severity of such incidents and they should be immediately reported to the highest authority in the hospital or organization. Quality improvement tasks should be undertaken by the staff to minimize the harm caused to the patient (Bouldin et al., 2013). During admission, all patients should be subjected to a screening measure, which will help to assess the proportion of risk in them for such falls. If some patients are found to be more vulnerable to such incidents, they should be given special care in the ward. Nothing as such was followed in during Betty’s treatment. Her medical charts were not updated and the nurse did not pay attention to her disoriented condition even on insistence. This lack of professionalism led to her accident and the injury could prove fatal had not the other patients alerted the nurse. This standard also promotes the practice of informing the patient and the caregivers about the risks and prevention strategies of such falls. If the staff is not well informed about such incidents then they will not be able to analyze the importance of such situation and will fail to provide required care to the patient (Deandrea et al., 2013). On the other hand, if a patient and the family members are well informed, they can remain alert. Fall prevention strategies should be developed in partnership with the caregivers and patient to make both of them well acquainted with the harms and risks associated. It is evident that the Australian health safety standards were not followed properly, which worsened Betty’s condition. She required a surgery and the wound developed an infection.

Surgical site infection occurs due to bacteria that invade the incisions made at surgery. It leads to antibiotic resistance spread in the patient and affects many people. There are certain ways by which surgical infection can be prevented or managed. The hospital staff should always maintain hygiene by washing their hands before treating a patient. Alcohol based hand sanitizers and cleaners are best effective in removing bacteria. The bedrails, tables should be wiped to remove any bacteria that can lead to infection. First few days following surgery, a patient should bath using chlorhexidine soap to remove bacteria from the skin (Dumville et al., 2013). IV should be inserted and removed under proper conditions and changed every four days. The hospital staff should be immediately informed if any inflammation occurs.

Certain recommendations need to be followed in the ward to avoid any cases of falls. After monitoring the patients who are vulnerable to falls, they should be given armbands, which acts as a visual clue and alerts staff about their risks. Clinicians and staff can initiate proper protocols to reduce risks of falling. Safety companions should be allowed to accompany disoriented people to help them follow directions. They continuously observe the patients and prevent falls. Keeping a patient busy with activities would make them less likely to come out of bed. Bed alarms should be set up to inform staff whenever a patient gets out of bed (DuPree, Fritz-Campiz & Musheno., 2014). This will help in direct monitoring. Safety rounds should be conducted twice for all high risk patients to check for all precautions that can prevent falls.

References

Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L., ... & Kaye, K. S. (2014). Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S66-S88.

Bouldin, E. D., Andresen, E. M., Dunton, N. E., Simon, M., Waters, T. M., Liu, M., ... & Shorr, R. I. (2013). Falls among adult patients hospitalized in the United States: prevalence and trends. Journal of patient safety, 9(1), 13.

Calfee, D. P., Salgado, C. D., Milstone, A. M., Harris, A. D., Kuhar, D. T., Moody, J., ... & Yokoe, D. S. (2014). Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S108-S132.

Carpman, J. R., & Grant, M. A. (2016). Design that cares: Planning health facilities for patients and visitors (Vol. 142). John Wiley & Sons.

Deandrea, S., Bravi, F., Turati, F., Lucenteforte, E., La Vecchia, C., & Negri, E. (2013). Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Archives of gerontology and geriatrics, 56(3), 407-415.

Digby, R., & Bloomer, M. J. (2014). People with dementia and the hospital environment: the view of patients and family carers. International journal of older people nursing, 9(1), 34-43.

Dixon-Woods, M., McNicol, S., & Martin, G. (2012). Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf, bmjqs-2011.

Dumville, J. C., McFarlane, E., Edwards, P., Lipp, A., & Holmes, A. (2013). Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev, 3(3).

DuPree, E., Fritz-Campiz, A., & Musheno, D. (2014). A new approach to preventing falls with injuries. Journal of nursing care quality, 29(2), 99-102.

Faull, C., & Blankley, K. (2015). Palliative care. Oxford University Press, USA.

Ganz, D. A., Huang, C., Saliba, D., Miake-Lye, I. M., Hempel, S., Ganz, D. A., ... & Ensrud, K. E. (2013). Preventing falls in hospitals: a toolkit for improving quality of care. Ann Intern Med, 158(5 Pt 2), 390-396.

Goldberg, S. E., Bradshaw, L. E., Kearney, F. C., Russell, C., Whittamore, K. H., Foster, P. E., ... & Porock, D. (2013). Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial). Bmj, 347, f4132.

Gray-Miceli, D., Mazzia, L., & Crane, G. (2017). Advanced Practice Nurse-Led Statewide Collaborative to Reduce Falls in Hospitals. Journal of nursing care quality, 32(2), 120-125.

LaRussa, K. A. (2012). A Practice-Based Research Approach to Explore the Relationship of Preoperative Warming to the Incidence of Surgical Site Infection in the Ambulatory Surgical Patient.

Rasouli, M. R., Restrepo, C., Maltenfort, M. G., Purtill, J. J., & Parvizi, J. (2014). Risk factors for surgical site infection following total joint arthroplasty. JBJS, 96(18), e158.

Smeulers, M., Van Tellingen, I. C., Lucas, C., & Vermeulen, H. (2012). Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. Cochrane Database of Systematic Reviews, 7.

Soni, A., Vollans, S., Malhotra, K., & Mann, C. (2014). Association between smoking and wound infection rates following calcaneal fracture fixation. Foot & ankle specialist, 7(4), 266-270.

Weber, J. R., & Kelley, J. H. (2013). Health assessment in nursing. Lippincott Williams & Wilkins.

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