Delivery in day(s): 4
NURS11159 Introduction Nursing Paper Editing Services
The essay gives a detailed account of the death of Vanessa Anderson, a 16-year-old girl residing in New South Wales. In the year 2005, Vanessa was hit in the head by a golf ball and was admitted to the Royal North Shore Hospital in New South Wales. Due to the lack of proper hospitality system and the poor mode of communication between the departments of the hospital, the family of Vanessa suffered a major shock. Vanessa lost her life at a very tender age due to medical negligence. This case brought to focus the importance of hospitality systems and the communication errors that lead to the loss of lives.
The essay sheds light on the factors that lead to the failure of communication in the hospitality sector. It also gives a detailed account of the communication errors and the impact it has on the service users. The role of registered nurses during emergencies is also focused in this essay. Furthermore, the essay gives an account of the findings of the coroner and identifies the major factors that led to the death of Vanessa. Recommendations are provided regarding the improvement of the communication system in the hospitality sector.
Factors that lead to failure of communication:
According to Carayon et al. (2014, p. 14) poor communication is one of the major problems in the medical world these days. This problem has raised concerns among the people working in the hospital and the common people. Poor communication is one of the reasons for the increased number of deaths in the hospitals. Dekker (2106, p.44) points out that the biggest problem in the communication system is between the physicians. This is mainly due to the existence of ego among the professional people. Each wants to undermine the efforts of the other thereby, leading to the lack of care of the patients. The lack of communication prevents the advancement of the diagnosis. The professionals fail to come to a stable decision, thereby leading to the failure of identifying the cure. Carayon et al. (2014, p. 14) suggest that the common problem of delayed communication is as serious as that of failed communication. Delayed communication may lead to the failure to provide safety to the patients.
A patient may require immediate assistance upon being admitted to the hospital. Delayed communication regarding the requirements of the patient may lead to loss of time. Wu et al. (2012, p.723) state that miscommunication can also lead to the hampering of the health of the patient. Co-ordination and understanding among the nurses are important to take proper care of the patients. Starmer et al. (2013, p.2262) suggest that with the advancement of modern technology, hospital sectors may look to telecommunication in order to provide information about a patient. This is an effective method of communication as the messages can be transferred from one place to another without any efforts. Another factor that leads to the failure of communication is the lack of maintaining records. The social care workers need to maintain an updated record about the medicines that the patient has received and the medicines that are to receive during their time at the hospitality center.
Systems improvement and communication errors:
In the case of Vanessa Anderson, the findings of the coroner points out that the death occurred due to miscommunication among the nurses. The nurses involved in taking care of Vanessa gave her therapeutic dose of codeine four times and failed to provide any anti-convulsive drugs to prevent a seizure. The coroner also concluded that the death was caused not due to the hit of the golf ball but due to the occurrence of the seizure (Smh.com.au, 2016).
According to Wu et al. (2012, p.723), the lack of proper communication between the nurses and the lack of knowledge about the medicines contribute to the decay of health in a patient. In order to prevent this occurrence, the hospitals need to train the nurses effectively about the various medicines and their effects. In regards to this context, Singer and Vogus (2013, p.373) points out that the hospital sector needs to maintain a chart that outlines the effects and usage of various medicines.
In the case of Vanessa, it is seen that the lack of knowledge and miscommunication among nurses lead to the disaster. In the light of this event, it is necessary for the nurses to maintain a record book that keeps the details of the patient, their requirements and the times they have been diagnosed with medicines. This is effective especially in cases where the nurses have to work in shifts. The clinical handover of the information of the patients lead to a better understanding among the nurses and improves the system of communication (Mueller et al. 2012, p.1057). Another way to recommend this flaw is by recruiting employees who possess the knowledge of medicines. This is important because the nurses are the people whom the patients can approach in a case of emergency. With proper knowledge regarding the condition of the patient, the nurses can notify the suitable professional (Carayon et al. 2014, p. 14).
Role of registered nurses:
Fiabane et al. (2013, p. 2614) state that it is the primary duty of the registered nurses to provide for the safety of the patients in the hospital sector. They need to be alert regarding any activity that hints at the deterioration of the health of the patients. It is the duty of the nurses to report this deterioration to the concerned professional for the proper treatment of the patients. The role of registered nurses is to help the patient learn about the importance of keeping fit and not indulge in unhealthy activities. However, in some cases, it is seen that the nervousness of the nurses proves as a barrier to their duties. Other factors include the fear of the nurses in working with the professionals. It is the duty of the nurses to maintain and arrange the diagnostic set in proper order before the professionals arrive. The lack of knowledge regarding the identification of signs that suggest deterioration also contributes to the fear of the nurses.
Dubois et al. (2013, p.110) state that the safety of the patients should be the high priority of the nurses. In order to achieve the effectiveness of the nurses, the hospitals need to develop a team that can respond to the emergencies. The team must consist of the response team that helps to avert the crisis and improve the process of identifying deterioration signs. Williams et al. (2013, p.80) point out that systems have been developed to identify the deterioration issues and provide a framework to deal with these patients. The health safety hospitalitysector needs to develop an administrative structure that coordinates the activities of the response team. The aim of the administrative system is to provide proper facilities, education, training and support to the nurses regarding the topic of health deterioration. This will help the nurses to develop coordination between themselves and improve their process of communication (Kirsebom et al. 2013, p.886).
Contributing factors to Vanessa’s death:
Based on the report from the coroner, it is seen that the death of Vanessa occurred due to miscommunication and lack of knowledge about medicines. The absence of hospital related guidelines increased the likelihood of prescribing multiple medicines without knowing their side effects. The excess intake of codeine led to problems in the respiratory system of Vanessa. The absence of team lines and responsible nurses also contributed to the deterioration of health of Vanessa. The lack of knowledge about the various medicines and the antibiotics required to counter the effects also contributed to the death of the patient. Communication issue played a major part in the demise of Vanessa. The nurses did not have a proper understanding among one another and thus it led to the excess dosage of the medicine. Other factor was that the symptoms that developed due to the excess intake of medicines was not properly observed and reported by the nurses (The Australian, 2016).
These factors are main contributors to the death of Vanessa Anderson, a 16-year-old girl. From the analysis of the coroner’s report, the death of Vanessa was solely due to medical negligence. The factors are interlinked with one another and it is the duty of the hospital employees to ensure that these factors do not repeated. Williams et al. (2013, p.80) point out that the importance of patient safety is an important factor that every hospital needs to undertake. In this case, the importance of medical safety also played an important factor for the death of Vanessa. The hospital management staffs of Royal North Shore Hospital failed to provide a suitable place for Vanessa. She had been admitted to a room that was far away from the nurse's desk. Thus, the nurses did not carry out the observation of the patient effectively. This also points to the negligence of the hospitality sector. Thus, the death of Vanessa was due to the infidelity of the Royal North Shore Hospital.
From the coroner’s report, it is recommended that the nurses of Royal North Shore Hospital need to maintain a record book that will help them to keep updated information about their patients and their activities. The best way to do so is by using the information system that may help them to record and store their everyday activities. This will also help the nurses who take care of the patients by working at shifts. The hospital needs to maintain a good communication strategy in order to prevent any other tragedies. The communication system can be improved by implementing proper training methods so that the nurses can coordinate with each other effectively. Royal North Shore Hospital needs to provide education to the nurses so that they can identify and understand the effectiveness of the medicines.
The hospital needs to admit their patients and provide them proper rooms by considering their emergencies. In this case, it was essential that Vanessa is kept near the nurse’s desk for the smooth observation of the nurses. However, this was not the case. The nurses need to monitor every patient simultaneously and it is important to keep the patients close for monitoring. The nurses of Royal North Shore Hospital need to overcome their fear of reporting about the deteriorated condition of their patients. This can be done by providing them with the proper systems required for the identification of the symptoms. The managers need to educate the nurses and encourage them to be fearless about reporting their findings. It is the duty of the employees and the employers to work together for the betterment of the hospitality sector. Royal North Shore Hospital need to implement these recommendations in order to earn their trust among the people after this tragedy.
Hence, it can be concluded that the importance of communication in the hospitality sector has a severe impact on the lives of the people. Communication reduces the gap between the employees and the employers and help to create a feeling of understanding among them. The roles of the nurses should be delegated in a way that they do not feel overburdened. It is important for the nurses to maintain a record based on their daily activities. This helps to prevent any misunderstanding concerning the diagnosis of the patients. Education is also another important factor that the nurses must undertake in order to gain knowledge about the working of the hospitals.
From the report of the coroner, it is seen that the negligence of the nurses led to the death of Vanessa Anderson. The lack of knowledge among the nurses and proper coordination between them led to a tragic circumstance that tainted the reputation of Royal North Shore Hospital. Thus, it is important to identify the flaws that prevent the proper diagnosis of the patients. Medical flaws can be rectified by recommending suitable professionals, but in order to rectify the flaws in the management system, it is necessary for the manager to step up and take suitable actions.
Carayon, P., Wetterneck, T.B., Rivera-Rodriguez, A.J., Hundt, A.S., Hoonakker, P., Holden, R. and Gurses, A.P., (2014). Human factors systems approach to healthcare quality and patient safety. Applied ergonomics, 45(1), pp.14-25.
Dekker, S., (2016). Patient safety: a human factors approach. Florida: CRC Press.
Dubois, C.A., D'amour, D., Tchouaket, E., Clarke, S., Rivard, M. and Blais, R., (2013). Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. International Journal for Quality in Health Care, 25(2), pp.110-117.
Fiabane, E., Giorgi, I., Sguazzin, C. and Argentero, P., (2013). Work engagement and occupational stress in nurses and other healthcare workers: the role of organisational and personal factors. Journal of clinical nursing, 22(17), pp.2614-2624.
Kirsebom, M., Wadensten, B. and Hedström, M., (2013). Communication and coordination during transition of older persons between nursing homes and hospital still in need of improvement. Journal of Advanced Nursing, 69(4), pp.886-895.
Mueller, S.K., Sponsler, K.C., Kripalani, S. and Schnipper, J.L., (2012). Hospital-based medication reconciliation practices: a systematic review. Archives of internal medicine, 172(14), pp.1057-1069.
Singer, S.J. and Vogus, T.J., (2013). Reducing hospital errors: interventions that build safety culture. Annual review of public health, 34(3), pp.373-396.
Smh.com.au. (2016). How system fatally failed Vanessa - National - smh.com.au. Available at: http://www.smh.com.au/news/national/how-system-fatally-failed vanessa/2008/01/24/1201025048650.html [Accessed 28 Aug. 2016].
Starmer, A.J., Sectish, T.C., Simon, D.W., Keohane, C., McSweeney, M.E., Chung, E.Y., Yoon, C.S., Lipsitz, S.R., Wassner, A.J., Harper, M.B. and Landrigan, C.P., (2013). Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. Jama, 310(21), pp.2262-2270.
The Australian. (2016). Coroner blames hospital for death. Available at: http://www.theaustralian.com.au/archive/news/coroner-blames-hospital-for-death/story-e6frg6o6-1111115395031 [Accessed 27 Aug. 2016].