NUR3201 Case Study 1 Coronial Case of Mr Roy Jacobs Answer

1. Human Factor: Cognitive

The cognitive dimension of the Registered Nurse's involvement in the Roy Rodney Jacobs inquest underscores the complexity of healthcare decision-making. Despite completing their annual Q-ADDS ( Queensland Adult Deterioration Detection System) competency training, a notable gap in understanding the intricacies of the Q-ADDS scoring system emerged. This gap, unfortunately, impeded the nurse's ability to grasp the significance concealed within Roy's elevated Q-ADDS scores (Queensland Courts, 2017). Consequently, this lack of comprehension became a stumbling block, preventing the timely initiation of essential actions. In addition to this, it was further worsened by the failure to promptly alert the medical officer for a comprehensive review and to enhance the frequency of observations in response to the heightened Q-ADDS scores. Additionally, the cognitive factor played a role in the negligence of the Registered Nurse to follow up on the anticipated review of Roy's condition by Dr. Maja, even after Nurse B's communication. As a cumulative outcome, the cognitive limitations of the Registered Nurse had a tangible impact on the quality of care Roy received. (Queensland Courts, 2017).

2. Missed Assessment/Missed Opportunity

The inadequate grasp of the Q-ADDS scoring system by the Registered Nurse led to a critical lapse in comprehending the significance of Roy's elevated Q-ADDS scores, thereby resulting in a failure to implement necessary measures for the escalation of his deteriorating clinical condition. Furthermore, the Registered Nurse's failure to adhere to the anticipated protocol of involving Dr. Maja in evaluating Roy's state, subsequent to being apprised by Nurse B, proved to be a missed opportunity for a comprehensive medical assessment and a reevaluation of Roy's treatment strategy (Queensland Courts, 2017). A pivotal misjudgment occurred when the Registered Nurse deemed Roy to be stable based solely on a Q-ADDS score of 6. This led to a decision not to alert the doctor or initiate more frequent observations, ultimately resulting in an overlooked chance for heightened vigilance and medical intervention. This lapse stemmed from an incomplete grasp of the Q-ADDS tool and failure to continue with the requisite frequency of observations. Collectively, these oversights constituted significant shortcomings in detecting and appropriately addressing Roy's deteriorating health status (Queensland Courts, 2017). In the interest of patient safety, a more comprehensive understanding of assessment tools and a proactive approach to escalating concerns are imperative for healthcare professionals (Kim et al., 2020).

3. Strategy for Risk Mitigation

One strategy that aligns with the Registered Nurse's responsibility for detecting and responding to acute deterioration while also considering the National Safety and Quality in Healthcare Standard - Partnering with Consumers Standard is to establish a robust system of patient and family education on early warning signs and the importance of timely reporting. This strategy involves creating educational materials, workshops, and sessions for both patients and their families (Australian Commission on Safety and Quality in Healthcare [ACSQHC], 2017). Nurses, as frontline caregivers, can take the lead in providing these educational resources. They can proactively educate patients and families about the potential signs of deteriorating health, emphasising the significance of promptly reporting any concerns or changes observed in the patient's condition (Hui et al., 2018). By empowering families with this knowledge, they become active partners in monitoring and advocating for their loved ones' well-being. In addition to enhancing the family's understanding, this strategy contributes to a collaborative care approach that aligns with the healthcare standard (Kim & Oh, 2020). The family's involvement not only helps in the early detection of deterioration but also aids healthcare providers in gaining valuable insights from those who know the patient best. In reflection, these cognitive facets accentuate the intricacy of healthcare decision-making and the imperative of continued professional development to ensure competent and comprehensive patient care (ACSQHC, 2017).

References

Australian Commission on Safety and Quality in Healthcare. (2017). National Safety and Quality Health Service Standards. https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Australian Commission on Safety and Quality in Healthcare. (2017). User Guide for Aboriginal and Torres Strait Islander Health. https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-User-Guide-for-Aboriginal-and-Torres-Strait-Islander-Health.pdf

Hui, D., Hannon, B. L., Zimmermann, C., & Bruera, E. (2018). Improving patient and caregiver outcomes in oncology: Team‐based, timely, and targeted palliative care. CA: A Cancer Journal for Clinicians, 68 (5), 356-376. https://doi.org/10.3322/caac.21490

Kim, M. Y., & Oh, S. (2020). Nurses’ perspectives on health education and health literacy of older patients. International Journal Of Environmental Research and Public Health, 17 (18), 6455. https://doi.org/10.3390/ijerph17186455

Kim, S., Appelbaum, N. P., Baker, N., Bajwa, N. M., Chu, F., Pal, J. D., & Bochatay, N. (2020). Patient safety over power hierarchy: A scoping review of healthcare professionals' Speaking-up skills training. The Journal for Healthcare Quality (JHQ), 42 (5), 249-263.

Queensland Courts. (2017). Inquest Findings - Roy Rodney Jacobs. https://www.courts.qld.gov.au/__data/assets/pdf_file/0006/544254/cif-jacobs-rr-20171117.pdf

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