Best Nursing Intervention Practices to Preventable Death Assignment

Assignment Task

Details

The review of evidence assignment requires you to review the video or transcript of a preventable death true story, comparing, analysing and reflecting on the scenario leading to a preventable death and what could have been done differently, when compared to current best practice evidence and highlight the best processes to follow as a registered nurse.

Matt was a 16 year-old who died following a simple appendectomy, the following video is Matt's story told by his mother Heather and Karyn Bousfield, Director of Nursing, West Coast DHB. If you find the video too confronting to watch, then please read the video transcript provided instead.

Instructions

1) Examining best practice evidence, explain what ‘Don’t normalise the abnormal’ means and using the A-E systematic approach, review the video and identify the A-E “reg flag” signs of deterioration that were mentioned and how these symptoms were normalised. 

2) As the ward nurse looking after Matt on the night shift, highlight the importance of ‘documentation’ and provide an explanation about the nursing care requirements you would have implemented overnight, including when you would have asked for a clinical review and why?

3) Examine what ‘critical thinking’ is for a nurse and using best practice evidence, explain how Matt’s deterioration and respiratory arrest could have been prevented from a nursing perspective if critical thinking skills had been utilised.

4) As an almost registered nurse, reflect on what ‘Speaking Up’ means as a nurse, in the given situation and in Australia what processes and supports could you utilise, if you are concerned about a deteriorating patient.

Background

Matthew was 16-years-old when he developed appendicitis. His mum, Heather, took him to the local emergency department where he had surgery that night to remove his appendix. Matthew had complications following surgery and he stopped breathing. He was resuscitated, and was eventually transferred to the ward to recover, despite having coughed up pink foam. The following morning, Heather and her husband David received a phone call to say that Matthew wasn't breathing, and they rushed to be with him. He was transferred to Christchurch Hospital by air ambulance, with a five percent chance of survival. Once at Christchurch Hospital, Matthew had an MRI which showed his brain was not getting any oxygen. His family made the decision to turn off his life support. Matthew died of global hypoxia due to negative pressure pulmonary oedema. He should not have died and many opportunities were missed to intervene. In this video, Heather talks about the events leading up to Matthew's surgery and what happened in the two days afterward. The director of nursing at West Coast District Health Board, Karyn Bousfield, also talks about what went wrong, the systems and process that may have contributed to the outcome, and the recommendations made to improve these in the future.

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