Case Study

Mrs Spring is a 70 year- old woman who underwent a small bowel resection for bowel cancer at a metropolitan hospital on the morning of 21 May 2017. Mrs Spring was transferred to the Surgical ward post-operatively at 1430 hours following the procedure.

A Medical Officer (MO) assessed Mrs Spring at 1630 hours on 21 May due to the patient reporting abdominal pain and distension. Mrs Spring’s distended abdomen and pain levels were documented in the patient’s health record by the MO and a phone call was made to report this information to the surgeon who performed the procedure. Analgesia was prescribed (10mg morphine SC) at 1715 hours to be given PRN 6 hourly in response to the patient’s reports of pain.

Ms Tracey was the RN working on the 15-bed surgical ward with an Enrolled Nurse (EN) on 21 May. Ms Tracey had been a registered nurse for five years. As per hospital policy, Ms Tracey and the EN were the only two staff members rostered to the ward on night-shift that commenced at 2245 hours.

The surgical ward was at capacity on the night of 21 May. Two of the other male patients admitted to the unit were distressed; one was continuously vomiting post-cholecystectomy and the other a dementia patient who was post TURP, he had already experienced a fall on the afternoon shift. During the night, he was agitated and walking into other patient’s rooms.

There was also a female patient admitted to the ward who was very upset at being placed in a room with male patient’s due to her religious beliefs. This patient, who had very limited English language skills, was crying and expressing anger over the fact that hospital management had not resolved this issue as promised to the patient and her husband on the afternoon shift.

It was hospital procedure that staff in the Post-Anaesthesia Care Unit (PACU), located adjacent to the surgical ward assist the surgical staff when needed. The RN in-charge of the PACU on night-shift was required by hospital policy to regularly check by phone with the surgical RN to see if assistance was required. There was no request made for assistance by Ms Tracey on the night of 21 May despite the fact the in-charge of the PACU reportedly contacted Ms Tracey five (5) times throughout the shift.

At 0210 hours on 22 May 2017, Ms Tracey documented the following in Mrs Springs health record:                    ‘Temp 38.9, P 126, Resp Rate 28 and BP 105/70’

These were the only observations documented during the night- shift.

There was no evidence of analgesia administration documented on Mrs Springs medication chart by the time day-shift staff commenced work. The day- shift RN for 22 May did report that Ms Tracey had verbally stated that she had been “flat out” all shift and had “not finished her notes” by the time handover occurred.

At 0700hrs RN Tracey requested to morning staff that she handover at the nurse’s station as she had to get home quickly to get her kids to school but she would return later to complete her nursing notes. Morning nursing staff received handover from RN Tracey and proceed with their shift.

At 0745 hours, a PACE call was made on Mrs Spring. Her observations were Temp 39 degrees, HR 140bpm, RR 30 BP 80/46, SaO2 87%. Mrs Spring was moved to the Intensive Care Unit where she was successfully treated for Sepsis secondary to bowel contamination at the site of the anastomosis.