Quality, Safety and Risk

Table of Contents


Discussion and Analysis.

Conclusion and recommendation.

Reference list

Introduction to Evidence Based Practice

Caregiving in the paediatric department is always a challenging task as the interdisciplinary skill is always preferred in this domain of caregiving. As per the idea of McAllister et al. (2018), the identification, documentation and analysis of the vital signs and symptoms of the child patient is quite a critical task and this demands the combination of knowledge, critical thinking skill and technological skill of the nurses to identify the severity and crisis of the patient. However, as per the case study, the Registered Nurses (RN) of SDMH (Shoalhaven District Memorial Hospital), of the paediatric department are not that much technically enabled and responsible as well, that has triggered the fatality of Troy Almond. As per the case study, Troy died on 22 March 2016, (12: 50 PM) and Dr. Thompson, who was performing resuscitation to the patient, has declared the cause of death as unknown (Coroners Court New South Wales, 2020). Hence, from this angle, it can be analysed that proper diagnosis has not been done about the clinical issue of the patient. RN of SDMH have developed electronic medical records of Troy with FirstNet computer system and iView analysis has been done. However, SPOC (Standard Paediatric Observation Chart) has not been prepared properly along with BTF (Between the Flags) approach which has misguided the doctor to identify the deteriorating condition and the root heath issue of Troy. The patient has died with the issue of Streptococcal infection followed by septicaemia. As per the idea of Farrell & Nadel (2016), The Paediatric Sepsis Pathway can be identified with the development of SPOC and can be managed with effective implementation of BTF. However, in this case the booth has not been done which has misguided the detector and the responsibility is associated with the RN of the hospital.

Discussion and Analysis of Evidence Based Practice

At the introductory section of the study, the background of the case study and the issue in the management of critical patients at the paediatric department has been identified. As per the viewpoint of Orique & Phillips (2018), the management of the clinical deterioration of patients is one of the most crucial accountability of the RN and this includes the collection of the additional information about the patient, analysis of the same and development of critical decisions with the implementation of evidence based knowledge. Massey, Chaboyer & Anderson (2017) has added that pathological tests should be performed along with the continuous monitoring of the essential parameters like temperature, blood pressure, heart rate, oxygen saturation, breadth, consciousness and cognition skill of the patient. These should be performed by the RN, to control further deterioration of the patient. However, this has not been performed for the case of Troy Almond which has invoked an issue in the diagnosis of the disease of the patient. In the case study, it has been identified that the patient has been admitted with temperature 38.9 degree Celsius which has escalated to 39.8 degree Celsius with the fluctuation and elevation of heart beat. As per the viewpoint of Stayt et al. (2015), the fluctuation of body temperature and cardiac beat is the major indication of the deterioration of the patient which should be analysed and managed by the RN. In this case, the fluctuation of the temperature and the pulse rate of the patient has been monitored regularly but RN has not performed any intervention to manage the deteriorating condition of the patient.

On the other hand, the monitoring and documentation of the blood pressure of the patient is another primary task tagged with the responsibility of the RN in the management of the deteriorating patient (Australian commission on safety and quality in health care, 2017). However, in the case of Troy, the BP of the patient has not been checked and documented for a single time. The RN Mason has done the test of capillary refill (CRT) which has resulted in brisk but has not been documented in the EMR. As per the viewpoint of John et al. (2019), CRT is performed to identify the returning of the blood to the capillaries (distal), after being emptied with pressure. This is a visual test associated with cardiopulmonary assessment but is quite different than that of measurement of the BP. Hence, from this angle, it can be mentioned that BP is one of the major aspects of identification of deterioration of patients which has not been focused by the RN of the SDMH.

The management of the clinical data and preparation of the reports is another role of RN in order to point out and escalate the root cause of deteriorating condition of the patient (Omer, Suliman, & Moola, 2016). The case study of Troy has mentioned that the identification and documentation of the vital signs of the patient has been done in the EMR. Dr. Tajvidi has administered Panadol and Nurofen about 11:30 Am. In spite of the administration of both the drugs the patient has shown a rise of body temperature about 12: 16 PM up to 39.8 degree Celsius. As per the research work of Moore et al. (2019), the constituent molecule of Nurofen is Ibuprofen which is identified as an anti-inflammatory drug to minimise inflammation and fever. The identification of Nurofen is identified as antipyretic and analgesic, which certainly minimises body temperature (Drugbank, 2020). Additionally, Panadol has been administered for the patient which is also a widely used antipyretic. However, the administration of the combination of ibuprofen and Panadol has not been able to minimise the fever load and pulse rate of the patient. This is a major indication of deterioration of the clinical condition of the patient which has been missed by the RNs of the paediatric department. The knowledge in pharmacology is one of the major skills and clinical competence which always helps in the management of the deteriorating patient. The RN has gaps in this skill which has triggered the fatality of Troy.

The performance of a pathological test is another aspect that has also been missed by the RNs of Troy to identify the root cause of infection. As per the case study, EDMO of the hospital has taken initiative to do blood tests and RN Avis have collected blood samples with cannula insertion. However, the test has not been done with proper priority which has delayed the identification of the sepsis formation in the body. As per the viewpoint of Sproston & Ashworth (2018), enhancement of WBC count, specifically Neutrophil count along with ESR and C-reactive protein level in the patient body transparently indicates the occurrence of infection and sepsis. This factor has been supported by Professor Kesson in the time of the Coroner's investigation. Hence, from this angle, it can be mentioned that the RN has missed this opportunity and has a gap in the identification of clinical deterioration.

The case study has revealed that iview has not properly guided the RNs and doctors to identify the severity of the patient and has not helped in the identification of septicaemia development in the patient. As per the case study, the training in iview has been stopped since 2013 and BTF has appeared as quite tough for the RNs in the development of reports of the patients. As per the official report, BTF has been implemented as a safety net by Australian safety and quality health care commission, which determines the condition of the patient with the analysis of slippery slope (Pain et al. 2017). In the slippery slope, rapid response should be done after clinical review and in the case of no improvement of the patient advanced life support should be provided to the patient to prevent death. However, this has not been done for Troy which has invoked his death. Moreover, the five factors to manage the safety of patients are executed which includes governance, standard calling criteria, education, emergency response system and evaluation skill as well. In this case lacking is every context has been noticed. In the guidelines of ‘Recognition and management of patients who are deteriorating’ the aspect of BTF has been included which has mentioned RN should have first line emergency management training to manage the critical condition and should have technical skill as well (NSW Government, 2020). There is a strong rationale behind the acceptance of BTF for paediatric care. As per the official website, BTF act as a safety net to prevent sepsis kills (NSW Government, 2020). Sepsis is one of the major factors which have enhanced the mortality rate for infants in Australia. Approximate estimation have proved that about 5000 individuals per year dies due to sepsis and this can be managed with early warning tools like BTF (Australian Sepsis Network, 2020). Clinical Emergency Response System or CERS is highly efficient in the management of the patients with sepsis and this is the key factor which has promoted the acceptance of BTF in the management of the deteriorating paediatric patients. Troy has also died from sepsis due to Streptococcal infection which may be managed with the time effective tracking and visualising trend of BTF. The governance aspect of BTF has created visualising and tracking trend over time which helps in the early detection of the root cause for deterioration. However, this has not been used properly due to the lack of technical skill of the RNs. However, it has been noticed that BTF is quite complicated and demands special skill and training for handling by the registered nurses. Hence, this is one of the major limitations that have been identified in this early warning tool from the perspective of RN.

The technical skill helps in the development of SPOC, which is a coloured coded chart to identify the severity of the vital signs of the patient and has been implemented as mandatory for the patients within the age group of 1 to 4 years (Zhang et al. 2017). Troy is a patient of 2 years old but SPOC has not been prepared for him either in the paper format or in the digital format. This is one of the major deficiencies in the technical skill that has invoked high risk for the patient. This factor also indicates the lacking in the clinical competence and knowledge in the management of the paediatric patients.

Additionally it has been noticed that there is no such lacking in the effective communication, (both written and verbal) between the RNs. As per the viewpoint of Cho & Jeong (2018), lacking in the communication skill for nursing creates convection of fractional clinical data which invokes issue in diagnosis of the patient. However, no such factor has happened in this case and the RN has provided regular updates to the doctor, but, the lack of team work has been identified. This has triggered deterioration of the patient. The cognitive bias regarding diagnosis and medicine administration have been noticed in the RN which has triggered the deterioration of the infant patient and in spite of understanding the importance of SPOC and BTF, the RN have prepared only a view. From this event, cognitive dissonance can be identified.

Conclusion and Recommendation on Evidence Based Practice

At the end of the study, it can be mentioned that the technical skill, knowledge and skill of evidence based practices should be developed among the RNs to make them more competent in the management of deteriorating patients in paediatric caregiving.

The management of clinical deterioration for the paediatric patients is directed by Ryan’s rule in NSW. As per the official report, Ryan’s rule is represented as REACH which includes the aspects like Recognise, engage, act call and help (Dwyer et al. 2020). This is needed to be performed in the practical field by RNs in the management of the clinical issues of child patients. However, in this case, there is a gap noticed in the aspect of Recognition and Action. The RNs of SDMH are not technically competent which has decreased the skill in the recognition of the critical condition of the patient. Hence, the implementation of Ryna’s rule in the practical context helps in the escalation of the caregiving system for the paediatric department of SMDH. Moreover, this should enhance the safety issue and will decrease the mortality rate of the patients. As per the viewpoint of Manning et al. (2017), technical skill development programmes always help the nurse to enhance their technical skill in the management of RMR and enables them to analyse the condition and severity of the patio ns with the support of technology. In the context of SMDH the skill development programme should be arranged regarding the development of skill of the RNs about SPOC and BTF preparation.

Reference List for Evidence Based Practice

Australian commission on safety and quality in health care (2017). National Safety and Quality Health Service Standards- Second edition. Retrieved on 10 September 2020, from: https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Australian Sepsis Network, (2020). SEPSIS EPIDEMIOLOGY. Retrieved on 14 September 2020, from: https://www.australiansepsisnetwork.net.au/healthcare-providers/sepsis-epidemiology#:~:text=As%20approximately%205000%20people%20die,prostate%20or%20colo%2Drectal%20cancer.

Cho, M., & Jeong, H. (2018). A Convergence study of the Effects of Empathy and Communication skill on Clinical stress in Nursing students. Journal of the Korea Convergence Society, 9(11), 539-547. Retrieved on 14 September 2020, from: https://www.koreascience.or.kr/article/JAKO201809258121286.page

Coroners Court New South Wales (2020). Inquest into the death of Troy Almond. Retrieved on 10 September 2020, from: https://coroners.nsw.gov.au/coroners-court/download.html/documents/findings/2018/Findings%20-%20Inquest%20into%20the%20death%20of%20Troy%20Almond.pdf

Drugbank, (2020). Ibuprofen. https://www.drugbank.ca/drugs/DB01050

Dwyer, T. A., Flenady, T., Kahl, J., & Quinney, L. (2020). Evaluation of a patient and family activated escalation system: Ryan's Rule. Australian Critical Care, 33(1), 39-46. Retrieved on 10 September 2020, from: https://www.sciencedirect.com/science/article/pii/S1036731418300675

Farrell, D., & Nadel, S. (2016). What’s new in paediatric sepsis. Current pediatrics reports, 4(1), 1-5. Retrieved on 10 September 2020, from: https://link.springer.com/content/pdf/10.1007/s40124-016-0093-4.pdf

John, R. T., Henricson, J., Anderson, C. D., & Wilhelms, D. B. (2019). Man versus machine: comparison of naked-eye estimation and quantified capillary refill. Emergency Medicine Journal, 36(8), 465-471. Retrieved on 10 September 2020, from: https://emj.bmj.com/content/36/8/465.abstract

Manning, J. C., Carter, T., Latif, A., Horsley, A., Cooper, J., Armstrong, M., ... & Wharrad, H. (2017). ‘Our Care through Our Eyes’. Impact of a co-produced digital educational programme on nurses’ knowledge, confidence and attitudes in providing care for children and young people who have self-harmed: a mixed-methods study in the UK. BMJ open, 7(4). 348-449. Retrieved on 10 September 2020, from: https://bmjopen.bmj.com/content/7/4/e014750.abstract

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nursing open, 4(1), 6-23. Retrieved on 10 September 2020, from: https://onlinelibrary.wiley.com/doi/abs/10.1002/nop2.53

McAllister, J. W., Keehn, R. M., Rodgers, R., & Lock, T. M. (2018). Care coordination using a shared plan of care approach: From model to practice. Journal of pediatric nursing, 43, 88-96. Retrieved on 10 September 2020, from: https://www.sciencedirect.com/science/article/pii/S088259631830109X

Moore, N., Duong, M., Gulmez, S. E., Blin, P., & Droz, C. (2019). Pharmacoepidemiology of non-steroidal anti-inflammatory drugs. Therapies, 74(2), 271-277. Retrieved on 10 September 2020, from: https://www.sciencedirect.com/science/article/pii/S0040595718302476

NSW Government, (2020). Recognition and management of patients who are deteriorating. Retrieved on 10 September 2020, from: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2020_018.pdf

Omer, T. A., Suliman, W. A., & Moola, S. (2016). Roles and responsibilities of nurse preceptors: Perception of preceptors and preceptees. Nurse education in practice, 16(1), 54-59. Retrieved on 10 September 2020, from: https://www.sciencedirect.com/science/article/pii/S1471595315001195

Orique, S. B., & Phillips, L. J. (2018). The effectiveness of simulation on recognizing and managing clinical deterioration: meta-analyses. Western Journal of Nursing Research, 40(4), 582-609. Retrieved on 10 September 2020, from: https://journals.sagepub.com/doi/abs/10.1177/0193945917697224

Pain, C., Green, M., Duff, C., Hyland, D., Pantle, A., Fitzpatrick, K., & Hughes, C. (2017). Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System. International journal for quality in health care, 29(1), 130-136. Retrieved on 10 September 2020, from: https://academic.oup.com/intqhc/article-pdf/doi/10.1093/intqhc/mzw132/17669166/mzw132.pdf

Sproston, N. R., & Ashworth, J. J. (2018). Role of C-reactive protein at sites of inflammation and infection. Frontiers in immunology, 9, 754. Retrieved on 10 September 2020, from: https://www.frontiersin.org/articles/10.3389/fimmu.2018.00754/full

Stayt, L. C., Merriman, C., Ricketts, B., Morton, S., & Simpson, T. (2015). Recognizing and managing a deteriorating patient: a randomized controlled trial investigating the effectiveness of clinical simulation in improving clinical performance in undergraduate nursing students. Journal of Advanced Nursing, 71(11), 2563-2574. Retrieved on 10 September 2020, from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12722

Zhang, L., Zhang, M., Liu, K., Bu, X., Xie, W., Lin, X., ... & Wang, X. (2017). Effect of flipped class model based on SPOC in the course of pediatric nursing. Chinese Nursing Management, (4), 17. Retrieved on 10 September 2020, from: http://en.cnki.com.cn/Article_en/CJFDTotal-GLHL201704017.htm

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