Patient Safety Using Coroner Findings

Analysis

Discuss about the Patient Safety Using Coroner Findings.

It is almost incalculable on the contribution of nurses towards the health and wellbeing of individuals and the whole community. Nursing as a profession promotes public health and eases the pain and suffering advocated for the weak and vulnerable so as to attain quality health. Healthcare provided by qualified nurses initiates the following; saving a life, preventing complications and sufferings, and improving the well-being of individuals. However, they face a lot of challenges for instance, when a patient dies in front of them due to poor decision making and failure to provide the necessary care to the patient. This essay critiques on the analysis of nursing, the tort of negligence and the ethical issues.

SM is a patient who died from pulmonary embolism originating from deep vein thrombosis in the right calf after undergoing surgery in the hospital for treatment of a ruptured appendicitis. Despite SM’s previous sickness, what led to his death can be put into judgement especially to the health care team, as such, a report on the findings of the coroner showed that there is an explicit failure on the intervention team in identifying and investigating the cause of his unrelenting saturations of low oxygen levels.

When the health care team used oxygen to manage low oxygen saturations on SM, it depicts a presence of poor decision making tactics by the initial treatment team. For a nurse to carry out a significant role in the health of a patient, a consultation is always needed from either conducting an investigation or enquiring information from medical officers (El-Jardali, et.al, 2011). However, findings from the coroner shows that oxygen was used and adjusted between low flow through nasal prongs and high flow through Hudson mask. In this case, medical intervention and an investigation were required so as to identify the cause before making a decision. 

Nevertheless, an arterial blood gas test was not done on the patient, SM, because they thought hypoxia and low saturations were not under considerations and this should have been done. As such, it indicates how poor decision making is in the health care team especially in nursing. According to research, decisions that nurses make should first be investigated and consulted with the medical doctors since decisions require specialist expertise. Arguably, the death of SM resulted from his conditions, but it seems to have been a combination of systemic issues encompassing decisions that were made in the treatment process.

Best Practice and Patient Safety

Appropriate prophylaxis includes a first dose of chemical prophylaxis either pre-operatively or intra-operatively. However, the findings indicated that SM did not receive heparin treatment until the following day at 8.00 am. Despite the case not contributing to the death of SM, it shows poor care provision. Also, there was no record of the treating surgical team of the VTE risk assessment and thus can indicate ongoing inadequate care provision since they fail to comply with the procedure of VTE prophylaxis of the hospital. Research suggests that compliance with a documented risk assessment for VTE prophylaxis during surgery is essential when it comes to incidents of accidents and investigations (Melnyk, Gallagher-Ford &Fineout-Overholt, 2014).

Failure to complete an observation form on the early morning was an indication of poor care at the local hospital. From the findings, it was noted that some observations were not on the record, not in trend and not documented, if they were there, they were not added correctly. The provision of care given by a nurse is essential for the health outcome of a patient (Chassin& Loeb, 2011). It is necessary for nurses and practitioners to be sensitive on what is required of them in administering healthcare to the patients.

A healthcare team should translate to providing their level best care to patients. This includes watching patients’ wellbeing, their situations and making early recognition on clinical deterioration so as to ensure their patients are in the proper status of improvement. To provide best practices, nurses can utilize their psychomotor domains such as coordination and physical movement. In nursing skills, it is essential for them to be competent to fundamental safety and efficient practicing. A psychomotor skill requires training, commitment and practice for better performance in techniques of safety, correct sequencing and accuracy.  Nurses can use psychomotor skills to make observations on the patient and be under close supervision of a medical doctor. They should perform the skill independently while coordinating and modifying the skill so as to be accurate and be competent.

Communication is required in the environment of health care right from senior doctors to those below them. One of the incidents that arose in SM's condition was failure to communicate by the nurse to the top medical doctors. Open communication between hospitals, nursing assistants, nurses in charge, directors and administrators and other staffs is the key to keeping problems from becoming severe" (Rilley, 2015)). Though nurses are required to apply oxygen to patients so as to offer support, they should first communicate before carrying out the procedure. 

Tort of Negligence

Monitoring is essential for better practice in nursing so as to observe the changes being made by the patient. Monitoring is recommendable for patients with worse and sudden conditions so as to be able to take immediate action and avoiding increasing risk to the patient. Control of health is the requirement of nurses by the health care (DeWit& O'Neill, 2013). It is an ongoing collection that is purposeful by interpreting and synthesizing data for clinical decision making with the aim of identifying and preventing probable problems. The practice involves skill in the exploit of devices for monitoring so as to measure the oxygenation and other states such as neurological respiration status. Monitoring is about thinking critically about the probable reason for changes in the vital signs of a patient. Research indicates that to monitor is to think far from the obvious in treatment construction then formulating a strategy to intervene the recognized results of the patient (Elliot &Covetting, 2012).

Reporting involves the nurse and the patient playing a role in ensuring there is safety. A patient is supposed to report any pain and anything that he or she might be uncomfortable with so as the right action is taken (Huber, 2013). On the other hand, nurses are to report on any matter that seems critical and beyond their effort. They should ensure they report on the medicines which they give to the patient so as to create awareness to the medical officer.

Accountability and responsibility- The nurse is the key and prime link to a patient in access to medical care. In the correctional setting, exploitation of nursing processes such as detailed assessment is critical to the outcome of the patient (Hood, 2013). Nurses are accountable in collecting detailed data in a systemic and ongoing procedure in using tools and techniques that are appropriate so as to construct a coherent plan and be able to give subsequent care (Solbrekke& England, 2011).  They are responsible for promoting the provision of safe, appropriate and ethical care. Nurses are to evaluate their own practice and undertake activities that are meant to improve practice. They are also answerable for their actions and professional conduct. They are responsible for working together with the patient so as to make sure the health of the patient is progressing well.

A tort of negligence is being careless and signifies a failure to exercise care that is the standard which another reasonable person should have applied in the circumstances. There is a statutory duty in taking care when it is reasonable in foreseeing failure that is likely to cause injury (Swisher, 2011). Negligence is when many kinds of harms are created by the inability to take adequate precautions. Unintentional tort is usually a negligence which conducts falls below the standard care while malpractice is negligence that is conducted by a professional nurse or a physician. Medical negligence takes place when professionals of heath care fail to carry out a reasonable medical professional (Nettina, Msn &Nettina, 2013). The malpractice is seen as conduct that is somehow mere negligence since the medical malpractice is usually negligence by the provider of health care that caused the injury to the patient.

In this case, SM has low oxygen saturation in his body and reduced breath sounds at the bottom of his lungs. The patient sits out of bed all day,  a repeat x-ray and ongoing chest physiotherapy is carried out with no medical credentials on the low saturations on SM and this is to show negligence by the nurses. Also when they take an action of applying and changing level flow through nasal prongs and high flow through Hudson mask the nurses show their negligence or failure to carry out investigations from the medical officers who are around despite their increased support in administering the oxygen saturations. The purpose of the nurse was not to conduct harm to SM. However, their failure to seek first guidance and consultation from the medical seniors indicates their negligence (Studdert, et.al., 2011).

In the current medical malpractices lawsuit, the plaintiff must be proven in the following elements and must be established by a preponderance of the evidence.

The defendant owing the plaintiff a reasonable duty of care- the plaintiff must indicate that the nurse had a role in giving care to the plaintiff. It can be easy for the plaintiff to be proven since once nurses undertake their care; they have an apparent role in providing care for the patient in a way that is competent and reasonable (Shandell, Smith & Schulman, 2015). All nurses owe a duty of precise care to all patients.

Breached duty of a defendant- this occurs when a nurse doesn't do what a reasonable nurse would have done when in the same situation, thus it can mean that a nurse can fall below the acceptable standard of care.

Incurred injury, loss or harm to the defendant- in proving the element of damage, the plaintiff must be capable of establishing experienced physical harm, lost money or actual decline in the life quality of patient (Kessler, 2011). As such, it will help to determine the monetary indemnity that will be rewarded if plaintiff at trial succeeds and works out.

Clinical discipline gives a structural loom to help physicians to recognize, examine and resolve ethical issues. It also requires knowledge on ethical matters such as informed approval, confidentiality and much more.

The principle of respect for the autonomy-Any notion of ethical decision making assumes that agents of rationale are engaged in decision making that is informed and voluntary. The decision of the patient and autonomy must be respected as well as the physician must carry out to avoid harm and give a medical benefit (Johnstone, 2015). In SM’s case, he had informed the doctor on where he was feeling the pain, but the doctor went out and carried surgery thinking it could be related. Here, the prima facie of the physician is to respect the choice of the patient.

Non-maleficence principle- it requires that no harm should be intentionally created to the patient. It affirms on the medical need of the patient so as to protect him or her from damage. In some cases, it might be difficult to choose from imminent harm, for instance in the case of SM; it was hard for the nurses to escape the damage that SM was experiencing. The case might be confusing since the single action and a decision could have an effect on the outcome of the patient. Therefore it is good for the practitioners to consider the nature of the act, the intention of the agent and the difference between means and effects.

Beneficence Principle- health care has duties in being the benefit of the patient as well as undertaking steps in preventing and removing harm from the patient. This principle should be given the priority over others especially in Emergence Medicine (Veatch, 2016). At the time of surgery of SM, nurses could communicate with the senior doctors, but no action was done. When a physician acts from a spirit of benevolence in giving treatments that are beneficial, then that is often the best interest in the eye of the patient. When SM is under surgery, a justified paternalism should be seen in the treatment of SM and the communication being given to the medical doctors.

Conclusion

In general, Nurses have a role to carry in the health of all individuals in the hospital and the society. They should work keenly by ensuring they maintain the ethic of their professionalism for better well-being and health of all people. 

References

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