Overview
The case follows the events that led to the unfortunate death of Whitney, a patient at a local hospital. Other main characters include Kelly (a visiting caregiver), Nathan (the unit director), Janice (an infections preventionist), Manuel (a third-year medical student), and Dena (an RN). In this case, the sentinel issue is the death of Whitney following an episode of untreated Hospital Acquired Infection (HAI). Whitney was undergoing treatment at the facility for appendicitis. Upon a successful appendectomy, the staff had her transferred to a recovery unit for an overnight stay. However, events following the stay led to an acquisition of an infection that would eventually lead to her death.
The HAI in question was an MRSA, which resulted in death due to severe sepsis. Now, MRSAs are a type of hospital-acquired bacterial infections. MRSA often spread through contact with infected wounds or contaminated hands. It any healthcare setting, MRSA cause serious health issues such as pneumonia, bloodstream infections, and surgical site infections (SSIs). Note that MRSA infections can resist treatment attempts from numerous common antibiotics making them hard to treat. This complication allows the infection to spread and become life-threatening to otherwise non-critically ill patients such as Whitney (CDC, 2014).
Barriers in communication and healthcare practices
The primary drivers of communication barriers in Whitney’s case include the unit director, the RNs, Kelly, Manuel, and Janice. It reveals numerous communication hurdles among these major characters as follows. First, there was a lack of proper communication channels to prepare physicians for their shifts. Second, there was a lack of clear interaction among the primary nurse, Kelly, and the secondary care nurse in between Kelly’s dad and Whitney’s treatment. This miscommunication resulted in poor patient care. Third, there was limited or no physical communication in between physicians during handovers and shifts. Furthermore, the facility lacked a streamlined resolution of issues and concerns among the staff. Lastly, none of the staff showed concern to engage in timely response to hospital related issues (Wong, et al., 2015).
Also, there were two breakdowns in standard healthcare precautions that occurred in this case as follows. First, nurses that handled both patients at the facility had poor hand hygiene practices. They did not see the need to practice appropriate hand hygiene after touching patients and other contaminated surfaces before handling patients. One nurse, for instance, did not wash her hands between patient contacts. Her actions indicated that she would most likely transfer organisms from Kelly’s dad to Whitney (CDC, 2014).
Second, most of the hospital’s characters lacked proper gloving techniques. For instance, Kelly did not remove her gloves after contact with her dad and the surrounding environments. Dena did not compel her colleague to wear gloves though she had just come into contact with a contaminated surface on her way to attend to Whitney’s IV Line. It did not occur to such characters that gloves are important when caregivers anticipate coming into contact with possibly infectious fluids. Therefore, proper gloving techniques would have helped in preventing contamination and the spread of infection (CDC, 2014).
Other potential healthcare barriers include the following. First, Janice met a lot of resistance from primary caregivers to change clinical behaviors. Second, nurses such as Dena faced pressures from patient care among other responsibilities. Third, Nathan lacked the time to address the need and importance of infection prevention techniques. Fourth, characters like Kelly and Manuel lacked adequate literary on proper patient handling techniques in practical situations. Lastly, there was laxity in the implementation of strategies that would improve hand-over processes (Wong, et al., 2015).
Nurse Administrator’s Role
The nurse administrator’s role in the identification and correction of these barriers are as follows. First, the administrator can enhance their supervision skills of members of the nursing staff. This role includes scheduling employees, evaluating practices, counseling, and training personnel. The administrator would also act as a mentor and model in ensuring the RNs and student physicians such as Manuel adopt proper clinical practices. Second, the nurse administrator is a leader that represent the needs of all employees. They facilitate communication between various members of the nursing staff and the administration. Typically, Nathan acts as a liaison between professionals such as Dena and Janice to help improve their standards of practice (Drolshagen & Chicano, 2009).
Third, nurse administrators engage in the creation and implementation of an appropriate budget to aid in improving health care. Closely related to this role is the implementation of business decisions that will facilitate care delivery. For instance, Nathan is responsible for ensuring that the unit is running with the efficiency required to reduce the risk of infection. Finally, administrators are the developers and implementers of policies aimed at enhancing the patient’s level of understanding clinical guidelines and practices. Nathan has an important role in assessing the effectiveness of clinical practices such as gloving, hand hygiene, communication, and handover. Such policies have a vital role in reducing the incidence of HAI (Wong, et al., 2015).
The Root Cause Analysis (RCA)
Cause analysis is a problem-solving technique that the administrator could use to identify the origin of a problem in practice. In Whitney’s case, a factor is a root cause if its removal from the sequence limits chances of deaths from recurring. For instance, an investigation into Whitney’s case shows that she died because of MRSA and severe sepsis. The investigation also shows that the HAI happened as a result of a contaminated wound infection during routine practices. The investigation further shows that the contamination happened due to poor communication and gloving strategies. The last investigation shows that there was no enough training on the importance of multidisciplinary communication and appropriate hygiene techniques. The root cause here is that training can help improve communication and hygiene strategies.
References
CDC. (2014, September 9). Methicillin-resistant Staphylococcus aureus (MRSA) Infections. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/mrsa/healthcare/clinicians/precautions.html
Drolshagen, C., & Chicano, S. (2009). Wound Care: Reducing Hospital-Acquired Pressure Ulcers. Journal of Wound, Ostomy and Continence Nursing, Vol 36 Iss 1, 45 - 50.
Wong, K., Rosario, L. B., Ang, W., Lim, A., Wild, D., & Chew, S. (2015). Preventing Pressure Ulcers in Hospitalized Patients. Conference Paper: Annual Scientific Meeting, At Changi General Hospital.
