Patient Safety Incident Involving a Student Midwife

Reflective account:

What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?

I experienced an event in which the client used the bathroom without the support and assistance of any midwife which led to the client to meet an accident. as the client was not under the care of the student midwife, she (student midwife) did not attend her (client) when client was going to use the bathroom which interfered with patient’s safety. on the request of a midwife, the student midwife formed an indecent report on this accident

What did you learn from the CPD activity and/or feedback and/or event or experience in your practice?

From the above-mentioned incident I have learned that the process of ensuring that patient’s safety by nurse and midwives must not be influenced by whether the patient is in under the care of the midwife or not. This incident teaches me that, it is the professional obligation as well as responsibility of a midwife to attend a client while it comes to ensure his or her safety irrespective of the fact that whether the midwife is assigned to the care delivery of that client. additionally, throughout the event I also have learned It is the prime responsibility of a nursing staffs or midwife (registered or student) to follow the systematic

How did you change or improve your practice as a result?

In terms of improving my practices in the context of above-mentioned event, I emphasized on improvising my understanding on the NMC guidelines that are set under the code ‘preserving safety’ (Conroy et al. 2017). Gathering in-depth and clear information regarding all the legal guidelines under this NMC codes assisted me to understand what are professional obligations of a midwife in terms of maintaining patient’s safety, I also improved my verbal and written communication skill, which assisted me to make regular interaction with client to understand the possible risks or hazards to which clients are vulnerable (Baumann et al. 2021). I also emphasized on improving early recognising and responding skill which helped me to determine the possible risk to the patient thereby setting the effective timely measures to make immediate response to these possible risks.

How is this relevant to the Code?

In the above-mentioned context that NMC Code “preserving safety “needed to be implemented and followed by the student midwife (Fagan et al. 2021). Under this NMC code, both the student and registered nurses or midwives need to ensure high level of patient’s safety throughout the care delivery process (NMC, 2015). By analysing the above-mentioned event I have released that, the NMC code “preserving safety” was not followed and implemented into practices by student midwife in the event which not only interfered with the health and safety of the client but also raised question on the professional accountability of the student midwife to maintain patient’s safety.

What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?

I had experienced an event in which a patient undertook a triage with a symptom of bleeding at her 28th gestational weeks. the patient was then referred to an obstetric. After performing all the health check-up and physical examinations of the patient, the doctor confirmed that the patient had no further bleeding. As the patient did not bleed at the time of check-up the student midwife sent her back to the home. on the very next day the patient delivered a baby and the student midwife identified that the entre diagnosis that had been made after the patient started bleeding was not appropriate. This event not only posed questions on the patient’s health and safety but also highlighted the inability of student midwife and the doctors to maintain their professional accountability towards promoting safe care to patient

How did you change or improve your practice as a result?

In the context of the above-mentioned event, I had made several improvements in my practice such as improve my time management skill, professional communication skill, listening ability, analysing and judgemental skill and interactive skill (Levett-Jones et al. 2020). I emphasized on improving my ability in maintaining transparent information delivery in workplace so that any kind of health decline in patient can easily be informed to the senior doctors and nurse (Lundborg et al. 2019). I also focus on improving my knowledge on how to provide the safe clinical support to the client with gestational bleeding. I also worked I on improving my professional accountability and integrity towards providing the safe and highly appropriate clinical response to the client in terms of eliminating any risk of blood borne infection during gestation bleeding.

How is this relevant to the Code?

In the above-mentioned event two NMC codes needed to be implemented and followed by the student midwife and doctors, the preserving safety and practice effectively (NMC, 2015). by analysing the above-mentioned event I have realised that, while dealing with patient suffering from the gestational bleeding, student midwife must follow the effective clinical procedures under which a safe and highly organised diagnosis and treatment of would be conducted (NMC, 2015). Additionally, under the NMC code practicing efficiently, I realised that a student nurse must ensure to have high degree of professional knowledge and skill that are enough to stop the gestational bleeding in patients (Mitchell et al. 2021).

What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?

During my practice I experienced an event in which, a client got a second-degree tear on her genital part during the childbirth. Here I worked as a student midwife under the instruction and guidance of the senior midwife. Despite using the local anaesthesia in genital part of the client, while the senior midwife started suturing the tear, the client informed that she suffered from severe pain due the suturing. Instead of responding to client’s pain, the senior midwife ignored the client ad continued the suturing. After realising that the patient suffered from severe bleeding, I suggested the senior midwife for informing the midwife in charge and doctor, but she denied my request, after some years the midwife understood her fault and instructed me to call the other team members for help. Then the doctor and the midwife in charge came and took the case over. After injecting appropriate medicine, the bleeding stopped and the client felt better.

What did you learn from the CPD activity and/or feedback and/or event or experience in your practice?

From this event I have learned that, while it comes to patient’s safety, a midwife must not think twice for seeking help from the other members of healthcare team to provide the immediate support to the patient (Pelzang and Hutchinson, 2019). Here I have learned that, while suturing client after the delivery, midwife must listen to the client properly to know that whether the client experiences any pain or health issue during suturing. Midwife must prioritise what patient inform or request during the suturing process to practice effectively and maintaining patient’s safety. I also learned that midwife must moisten carefully to the other team members in the team to make a synergistic approach of prompting patients’ safety

How did you change or improve your practice as a result?

I focused on improving my knowledge on medicine administration and medicine management that will assist me to administer the right medicine to patient’s body, to stop bleeding or other complication during and after childbirth.

How is this relevant to the Code?

Here I have realised that the senior midwife needs to follow and maintain two NMC codes such as prioritising people and preserving safety, through preserving safety, a midwife can provide the immediate clinical support to the patients thereby promoting their safety (NMC, 2015). Through prioritising people midwife can listen to the personalised care needs and health issues of client thereby focusing on these needs to meet them accordingly (Terry et al. 2017).

Take a deeper dive into Patient Interaction In A Role with our additional resources.

Reference list:

Baumann, S., Gaucher, L., Bourgueil, Y., Saint-Lary, O., Gautier, S. and Rousseau, A., 2021. Adaptation of independent midwives to the COVID-19 pandemic: A national descriptive survey. Midwifery, 94, p.102918.

Conroy, T., Feo, R., Boucaut, R., Alderman, J. and Kitson, A., 2017. Role of effective nurse-patient relationships in enhancing patient safety. Nursing standard, 31(49).

Fagan, A., Lea, J. and Parker, V., 2021. Student nurses' strategies when speaking up for patient safety: A qualitative study. Nursing & Health Sciences.

Jack, S.M., Munro‐Kramer, M.L., Williams, J.R., Schminkey, D., Tomlinson, E., Jennings Mayo‐Wilson, L., Bradbury‐Jones, C. and Campbell, J.C., 2021. Recognising and responding to intimate partner violence using telehealth: Practical guidance for nurses and midwives. Journal of clinical nursing, 30(3-4), pp.588-602.

Levett-Jones, T., Andersen, P., Bogossian, F., Cooper, S., Guinea, S., Hopmans, R., McKenna, L., Pich, J., Reid-Searl, K. and Seaton, P., 2020. A cross-sectional survey of nursing students' patient safety knowledge. Nurse education today, 88, p.104372.

Lundborg, L., Andersson, I.M. and Höglund, B., 2019. Midwives’ responsibility with normal birth in interprofessional teams: A Swedish interview study. Midwifery, 77, pp.95-100.

Mitchell, B.G., Russo, P.L., Kiernan, M. and Curryer, C., 2021. Nurses' and midwives’ cleaning knowledge, attitudes and practices: An Australian study. Infection, disease & health, 26(1), pp.55-62.

Murray, M., Sundin, D. and Cope, V., 2018. The nexus of nursing leadership and a culture of safer patient care. Journal of clinical nursing, 27(5-6), pp.1287-1293.

Ntlokonkulu, Z.B., Rala, N.M.D. and Ter Goon, D., 2018. Medium-fidelity simulation in clinical readiness: a phenomenological study of student midwives concerning teamwork. BMC nursing, 17(1), pp.1-8.

Pelzang, R. and Hutchinson, A.M., 2019. Patient safety policies, guidelines, and protocols in Bhutan. The International journal of health planning and management, 34(2), pp.491-500.

Terry, L.M., Carr, G. and Halpin, Y., 2017. Understanding and meeting your legal responsibilities as a nurse. Nursing Standard

Wahlberg, Å., Högberg, U. and Emmelin, M., 2020. Left alone with the emotional surge–A qualitative study of midwives’ and obstetricians’ experiences of severe events on the labour ward. Sexual & Reproductive Healthcare, 23, p.100483.