Assignment Task

1) Provide an introduction with a brief synopsis of the case

This is an inquiry held by the Professional Standard Committee about a tragedy on 22nd March 2016. Due to a lack of awareness of the symptoms of toxicity brought on by potential sepsis, the investigation into the possibility of sepsis, and the administration of antibiotics, an eighteen-month-old boy died of septicemia. Sean Robert Avis was the registered nurse who looked after the body from 10:30 am to 2 pm on 21st March 2016. The Health Care Complaints Commission makes three complaints about the care provided by Sean Robert Avis as following:

• Failure to undertake timely assessments;
• Inadequate care following the observation of a rash on the torso of the young boy
• Inadequate record-keeping

The inquiry was implemented over two days on 11 and 12 December 2019, and it investigated whether those complaints amount to unsatisfactory professional conduct in the circumstances. After the inquiry was viewed overall, Mr Avis`s conduct was considered unsatisfactory professional conduct when he was taking care of the young boy. However, it was not necessary or appropriate to give him any other protective order. Currently, he documents objective data without using any descriptive language. He now enters a note in the clinical records whenever he participates in discharge. The Paediatric Department Observation Chart documentation template, which offers instructions for a thorough A-G assessment and highlights observations that do not fit into the flags, has always been what he now uses. He accepted his past mistakes and said he had learned much from his ongoing studies.

2) Identify and discuss the ethical principles related to this case study.

In this case study, ethical principles of beneficence, nonmaleficence, and justice could be involved.

Breach of beneficence

In this case study, the breach of beneficence could be involved. Beneficence is referred to as acting in the patient`s best interest and is considered a moral principle (Lundon., 2023). In nursing care, the principle of beneficence can have a positive impact on patients` well-being and health. Ultimately, this can lower patients` mortality rates, increase patient satisfaction, and preserve patients` human dignity and respect (Cheraghi et al., 2023). This breach of beneficence could be reflected in Mr Avis`s delay to assess the young boy`s first assessment until about 11am. Since Mr Avis received the young boy`s handover at 10:30am, he was supposed to do the first assessment for this young body after the handover. However, he did not check the vital signs and only knew the allocated triage category at that time. This behaviour reflected that he did not behave in the patient`s best interest and even risked his safety because he did the first assessment for this young boy until 11:00am. He manages his nursing tasks and prioritises the most urgent issues.

Breach of nonmaleficence nonmaleficence

According to Varkey (2021), a health professional has an ethical duty to act in a way that does not harm their patients. In this case, Mr Avis made a mistake in the skin rash record for that young body; he recorded it as non-blanching when it was blanching. Though he acknowledged his mistake, this incorrect entry may be the misleading reason for the young boy`s diagnosis by the clinician. Another example could be the cessation of vital signs observation for the young boy before his discharge by Mr Avis. This misconduct could cause harm to the young boy as his physical condition had not been closely monitored. To achieve a beneficial outcome, nonmaleficence nonmaleficence requires doing no harm or doing the least amount of harm possible (Temsah, 2018). Obviously, the young boy did not receive the beneficial outcome of Mr Avis`s mistake.

Breach of Justice

According to Lisa (2023), every patient has the right to receive equitable treatment from others. In this case, the young boy `s situation was not treated equally. As Mr Avis admitted that he was socially acquainted with the mother through a friend and as a hospital nurse, this may potentially result in a lack of urgency in his observations and a misunderstanding or false sense of stability in the child`s health, which led to missing the best time to investigate the toxicity likely causing from sepsis. Therefore, Mr Avis was not compliant with the ethics of justice because of his own assumption.

3) Identify and discuss the legal principles related to this case study and include references to relevant legislation.

Negligence

Healthcare providers around the world are becoming more concerned about medical negligence, also known as medical malpractice, medical errors, and the tort system, as a public health issue. "An act of omission or commission in planning or execution that contributes or could contribute to an unintended result" is the most comprehensive definition (Thavarajah, Saranya & Priya, 2019, as cited in Dahlawi, 2021). Also, among all health professionals, negligence is the most frequent tort. Damages include death, as well as medical, pathological, and/or psychological harm brought on by a nurse`s carelessness (Cheluvappa, 2020). In this case, the death of the boy is caused by the negligence of Mr Avis. This can be reflected in the inadequate further care upon observation of a rash on the young child at 13:30. Though the medical practitioner had made the note to discharge the young child, Mr Avis did not analyze the actual case situation with clinical thinking skills. Therefore, Mr Avis`s negligent practice caused the young child`s situation not to get enough attention. Because nurses have more time to closely monitor patients than doctors, nurses are supposed to get to know the patients very well.

Breach of Registered Nurse Standards For Practice- standard 6 Provide safe, appropriate and responsive quality nursing practice

In the Registered Nurse Standards for Practice document, one of the contents of standard 6 is that registered nurses practice in accordance with relevant nursing and

health guidelines, standards, regulations and legislation (Nursing and Midwifery Board, 2023).

In this case, Mr Avis failed to assess the child`s vital signs every 30 minutes when his vital signs were not between the normal ranges. Even though he did the vital signs hourly and explained that he knew the "Between the Flag" policy was implemented in the wards, he was not aware that this policy should be applied in the emergency department. This behaviour reflects that he was not familiar with the protocols which are applied in his current working place; this can lead to his action did not provide a safe and appropriate nursing practice to his patient, and this will not promote his patient`s well-being. It is the responsibility of nurses to carry out interventions that assist patients and their caregivers (Tia et al., 2022).

Breach of Registered Nurse Standards For Practice- standard 1 Thinks critically and analyses nursing practice.

In order to make decisions and deliver safe, high-quality nursing care within person-centred and evidence-based frameworks, registered nurses apply a variety of thinking techniques and the best available evidence (Nursing and Midwifery Board, 2023).

In this case, Mr Avis ceased any ongoing care of the young boy once he knew the discharge was approved by the medical practitioner who treated the young boy. Mr Avis clarified that, at the time, the practice did not carry out routine observations after a patient was released from the hospital. However, he did not think critically about the young boy`s situation since the young boy had already had the rash, and this was a new observation, adding his vital signs were not between the flag before. On the basis of the above situation, Mr Avis still ceased his ongoing observation of the young boy without using his own clinical thinking, which is essential in the nursing practice. Therefore, his decision did not deliver safe and responsible care to this patient.

4) Identify and discuss the actions/omissions on the part of the Registered Nurse(s) in this case study that contributed to the adverse outcome for the patient

The lack of urgency

In this case, the young boy`s heart rate was 173 beats per minute when Mr Avis reviewed the triage note. According to NSW Health (n.d.), a heart rate reaching 170 or above could be the red zone criteria in a pediatric observation chart. If a child has any one of the red zone criteria present, rapid response is required; nurses also must take appropriate clinical care, notify the nurse in charge and repeat the patient`s observation. Obviously, Mr Avis did not take any appropriate action after he became aware of the young boy`s red zone criteria. What he did was only ask the young boy`s mother whether her child was all good. This unprofessional nursing practice resulted in the earliest deterioration being overlooked, and that led to missing the best time to investigate the young boy`s status. Even though Mr Avis explained that the child`s mother is also a nurse and a friend of his, it could not become the reason for this unprofessional behaviour. Therefore, the lack of urgency could be the main factor contributing to the adverse outcome for this young boy.

Inadequate further care upon observation of a rash

In this case, there was a new observation of a skin rash on this young boy`s torso at about 13:30. However, Mr Avis did not further care about this new sign; he just followed the medical practitioner`s diagnosis of the viral rash without having his own clinical judgment. This may result in the young boy`s deterioration getting worse due to insufficient nursing care. Patients are more likely to experience adverse events as a result of missing nursing care. Moreover, data indicates that not receiving nursing care can have a number of detrimental effects, such as lower levels of satisfaction for both patients and nurses, a greater propensity to quit, absenteeism, and more extended hospital stays (Janatolmakan &Khatony, 2022).

5) Identify and discuss any other factors that contributed to the adverse outcome for this patient.

The unsafe clinical system and governance

The adverse outcome for this young boy could be the Between The Flags policy because this policy was not the standard operating procedure in the emergency department at that time. Even though Mr Avis realized that this young boy`s vital signs should be monitored every 30 minutes, the system did not roll out in time to get this young boy`s vital signs entered. This reflects that this hospital system was not in a safe and effective governance. Ensuring that patient safety and quality incidents are identified, reported, analyzed, and utilized to enhance the care provided is a crucial responsibility of the organization`s safety and quality systems, and integrating these systems with governance processes is crucial to empowering health service organizations to actively manage risk and enhance patient safety and quality (Australian Commission on Safety and Quality in Health Care, n.d.). Therefore, the clinical system could play a crucial part in promoting patients` safety and quality care.

Lack of Evidence-based practice (EBP)

The other reason resulting in this adverse outcome could be the lack of evidence-based practice. This can be reflected in that there are some subjective descriptions of the young boy`s vital signs in Mr Avis`s recording by using "the cap refill is good". Mr Avis admitted that this recording is liable and that it was not helpful in the following handover to other health professionals. According to Abu-Baker et al. (2021), the practice environment and patient outcomes may both be enhanced by healthcare professionals incorporating evidence-based practice (EBP) into their routines, increasing their knowledge, standardizing their practices, and enhancing patient outcomes are imperative for nurses. Therefore, creating an evidence-based practice in the clinical environment is essential to the safety of patients.

6) Provide a conclusion outlining the main issues/errors identified and how these could be prevented from re-occurring in the future.

In this case, there are two main issues that need to be concluded. Firstly, Mr Avis breached the beneficence due to the delay in the vital sign assessment for the young boy. For medical emergency teams and early warning scores to work effectively, vital sign data is crucial (Hands et al., 2013, as cited in Elliott, 2021). For the prevention of

re-occurring, Global Elements of Vital Signs Assessment is proposed to help emphasize the importance of vital signs assessment. the Elements are based on national and international guidelines, the most recent research, and it is fundamental ideas that support the assessment of vital signs. In addition, it aims to address the enduring neglect of vital signs assessment and is a guideline for clinical practice (Elliott, 2021).

The other main issue is the lack of EBP practice resulting from the subjective note recording for this young boy by Mr Avis. This can reflect on there is a recording is “ cap refill is good”. In order to provide safe, high-quality care and achieve the best possible outcomes for patients, evidence-based practice, or EBP, has become the standard. Some strategies, including the use of educational materials, reminders, computerized decision support, performance feedback, opinion leaders, multi-professional collaboration, and mass media campaigns, could be used to build awareness of EBP (Tucker et al., 2020). All in all, raising awareness of the ethics of nursing and complying with the EBP practice is essential for a nurse`s future career.

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