SNUG303: Patient Narrative for Assessment Root Cause Analysis (RCA) - Medical Science Assignment Help

Assignment Task:

Task:

Description of Reportable Incident (Situation):
An unwitnessed fall of a 27-year-old male patient with a physical disability that resulted in a significant head injury.
Background Information
On the 18th of December 2020 at 15:16 hours a 27-year-old male, Bob Hughes presented to the major hospital Emergency Department (ED) via patient transport after being referred by his GP. The patient lived at home under the care of his mother, who was his full time carer. Bob also receives assistance for personal hygiene once a week from a private provider. The patient had a medical diagnosis of cognitive impairment secondary to cerebral palsy and past medical history of obesity, asthma, frequent lower respiratory tract infections, constipation and gastrointestinal disorders with steatorrhea/constipation alternation.

A triage category 4 (ATS 4) was allocated to the patient considering his presentation. The ED Medical Officer (MO) later reviewed the patient and collateral history was obtained from the patient’s mother, who reported ongoing issues with constipation but reported good compliance with medications. Medical assessment included palpation of his abdomen, which was found to be hard and tender to touch. Routine bloods were collected, which reported a low haemoglobin of 125g/L and elevated C – reactive protein (CRP) of 39.5 mg/L. Routine urinalysis was normal. The patient’s weight was recorded at 90 kilograms (kg). The patient was assessed as likely having delirium secondary to constipation. An abdominal X-ray was also ordered.

At 19:06hrs the patient was transferred from the ED to a medical ward, where he had ongoing treatment and care from the multidisciplinary team. The abdominal X-ray was reviewed and noted to be normal with no evidence of bowel obstruction. Movicol was administered to relieve constipation. The Ontario Modified STRATIFY (Sydney Scoring) Falls Risk Screen and Waterlow Risk Assessment Tool (WRAT) were completed on admission to the medical ward, with the results placing the patient at high risk of fall and pressure injuries. A Confusion Assessment Method (CAM) was completed at 21:30hrs and was negative for delirium.

On the 19 th of December at 13:07 hours, the Speech Pathologist (SP) reviewed the patient after a referral from the nursing team, noting that the patient refused a swallowing assessment and was asking for his mother. The SP’s recommendation included nutritional supplements in addition to his normal diet, regular mouth care, upright 90 degrees/alert for oral intake and keep the patient nil by mouth (NBM) if any signs of aspiration. Nursing documentation noted that the patient refused all his dinner and bedtime medications on this day.

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