A Case Study on Patient Harm and Poor Practice

  • 08 Pages
  • Published On: 03-06-2024

The main factors that contribute to safe and effective care are communication; leadership; safety culture; stress and fatigue; teamwork and work environment. This essay demonstrates a scenario involving patient harm and poor practice. It will focus on how important it is to get support from the provider- nurse in charge; failure from a multidisciplinary team showing poor practice which occurs while in practice when discharging a patient home without full care. It will present the disadvantage due to lack of staff on the ward and having not fully trained staff (new staff). Furthermore, this assignment is going to focus on what is going to be done after the accident which occurs in the bay due to poor practice including datex, involving new staff with extra training, as well as putting in place sensors to prevent fall.

The case of Mrs J informs that the key issues faced in the care are lack of fall prevention due to inadequate and untrained staff, lack of effective leadership from nurse in charge; arranging fall prevention equipment and maintaining hygiene for the patient. In safe and effective care for elderly patients, fall prevention and management of adequate hygiene is required (Poscia et al. 2018; Anto et al. 2018). This is because elderly people due to muscle weakness and presence of long-term condition becomes unable to take their own care and is prone to fall. This is evident from the case of Mrs J where due to her ailing health and weakness she is unable to manage her own hygiene and maintain balance resulting in fall during the stay at the hospital. According to NMC Code, the role of nursing individuals in safe and effective care delivery to the patients is presence adequate and competent skills and knowledge regarding the care being provided by them (NMC, 2018). However, in case of Mrs J, it was seen that the nurse allocated to care for her in the bay on the night in which the fall occurred was untrained and lacked adequate knowledge to determine safety to the patients. This indicates that the role of the nursing individual was not played effectively to ensure quality care to Mrs J.


The role of statutory and regulatory body in healthcare has the duty to ensure presence and implementation of adequate resources and policies are made by hospitals and healthcare institutions to avoid risk and harmful consequences to the patients for their safe care (Herbst et al. 2016). However, in case of Mrs J, it is seen that the statutory and regulatory body directing management of care in the hospital failed to ensure whether or not a risk-free and safe care environment is present indicating they did not execute their role effectively. The role of healthcare professionals for safe and effective care of the patients is to arrange an appropriate care plan as per the needs of the patients (Chamberlain, 2017). This is to ensure intervention and care strategies required for person-centred care of the patient is adequately met. However, in case of Mrs J, it is seen that the healthcare professionals did not play their role in effective manner due to which strategies to avoid fall and maintaining hygiene for the patient is not assured. Moreover, deterioration in her health condition is experienced out of lack of appropriate care by the professionals.

In reference to the Appendix, Mrs J is seen to have suffered a fall and is suffering from UTI along with requires support for her everyday living. Mrs J's case informs that there was irresponsibility from the hospital authorities, management bodies, social carer and nurses in managing her care. This is evident as the authorities did not assure safety from fall for Mrs J, the management bodies did not ensure skilled and trained nurses are appointed for care to Mrs J in her bay, hindered care delivery of nurses resulting in Mrs J's fall and carer responsible to support Mrs J performed hindered care due to which she was found to show lack of hygiene on admission. The action which was taken with priority is assuring patient safety. She was transferred to bed using HoverJack to allow us to transfer her from the floor to bed minimising the risk of further injuries to both patient and caregivers. The safe handling often adds up to the quality of care that patient receives as it prevents increased trauma to patients on fall (Thürig et al. 2016).

During the patient’s stay in the ward, continuous risk assessments and management were taking place. In line with the local safe discharge policy two weeks after the patient fell and treatment for UTI, Mrs J had a physiotherapy assessment for support and to ensure the patient knew her limitations. The physiotherapist assessed the patient’s mobility and instructed her how to safely transfer from bed to chair or toilet. The physiotherapist also provides patient with a range of exercises. This is to ensure that the patient feels comfortable returning to care home and that her mobility returns to baseline (Perracini et al. 2018). The physiotherapist for Mrs J also mentioned her exercises which she was asked to do minimum twice a day to get back to baseline in two to four weeks. Once the physiotherapy assessment was completed, and all other key points for safe discharge were confirmed, Mrs J was discharged to care home with the 24 hours support. The incident was reported to the sister in charge, by the staff nurse who was helping with the transfer. Datex has been recorded on the website using a reporting system. It is vital that the incidents are reported and properly investigated to identify problems and prevent further recurrence of any health issue among the patients after discharge (Khalifa, 2019).

The communication with the nurse in-charge is very important to ensure the exact duties to be performed for ensuring safety of patients. However, lack of communication with nurse in-charge leads to stress and anxiety on staff out of confusion in delivering care making them to easily develop mistakes when delivering personal care or dealing with medication (Redley et al. 2017). A similar condition is seen in case of Mrs J, where due to lack of effective communication and delegation of duty by nurses in-charge led to fall of the patient. Another incident which occurs during this scenario is failure from a multidisciplinary team showing poor practice when discharging a patient for the first time to home without thorough check and full care to meet the patient needs while being at home. The patient has not been fully assessed when discharged home. Her needs have not been taken into consideration when leaving the hospital which caused additional readmission to hospital. Patients receive very little help as she only had one visit per day from her carers which clearly show that she did struggle.

The contribution of safe and effective care for Mrs J would require me as registered nurse to develop better skills and knowledge in managing care for particular patients in the bay and for Mrs J. This is because patient was looked after a staff who were from a social care background but had little experience with the ward as knew to it and also lack of training when it comes to deal with dementia patients who suffers from UTI/confusion. It is very important to know the basic information about the condition, signs of confusion, being able to understand the ways of minimising falls in the elderly and be prepared to respond effectively and correctly when situations occur. In order to know the way to communicate with confused patients, I would talk to the manager or the educational team to arrange extra dementia training and manual handling courses. The understanding regarding risk assessment is required. This is because it aims to establish the level of care required, along with the areas of caution, and can be seen as fundamental to all patient care (Kim and Hood 2007). I would put in place equipment like sensor pad which alerts the staff immediately when the patient sits up in the bed with the intention of getting up, to prevent from falling Olveczky (2009).

I would involve Older People’s Mental Health (OPMH) to review the patient their responsibility is to provide assessment, treatment and support to older people (usually over the age of 65) experiencing mental health problems, in a setting that is most appropriate to their needs. Furthermore, I would talk to the sister in charge about the shortage of the staff during the shift as it is very important to have the right amount of staff to cover the ward, to make sure patient safety comes first and the care they receive will not have any impact on them. Leaving the ward short of staff causes a lot of stress and fatigue between staff and gives them a lot of pressure, where mistakes could happen more often during this time.

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The above discussion informs that Mrs J has suffered a fall in the hospital and facing hindered care out of lack of presence of skilled and trained staffs. The role of nursing individuals is to offer care to the patients in such a way so that enhancement of their health occurs and safe care is assured. The role of regulatory bodies includes supporting effective safe healthcare within healthcare organisation. However, in case of Mrs J, the roles are not followed leading to her hindered health condition. The error is practice for Mrs J has occurred out of irresponsible delegation of care, hindered use of healthcare equipment and inappropriate management of safe healthcare environment.


  • Anto, V. P., Brown, J. B., Peitzman, A. B., Zuckerbraun, B. S., Neal, M. D., Watson, G., ... & Sperry, J. L. (2018). Blunt cerebrovascular injury in elderly fall patients: are we screening enough?. World journal of emergency surgery, 13(1), 30.
  • Chamberlain, J. M. (2017). Malpractice, criminality, and medical regulation: reforming the role of the GMC in fitness to practise panels. Medical law review, 25(1), 1-22.
  • Herbst, R. B., Bernal, D. R., Terry, J., & Lewis, B. (2016). Undocumented Latina/o immigrants in multidisciplinary settings: Behavioral health providers’ role in promoting optimal, ethical healthcare. Journal for Social Action in Counseling & Psychology, 8(1), 89-108.
  • Khalifa, M. (2019). Improving Patient Safety by Reducing Falls in Hospitals Among the Elderly: A Review of Successful Strategies. Studies in health technology and informatics, 262, 340-343.
  • NMC 2018, NMC Code of Practice, Retrieved on 6th June 2020 from:https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf">https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
  • Perracini, M. R., Kristensen, M. T., Cunningham, C., & Sherrington, C. (2018). Physiotherapy following fragility fractures. Injury, 49(8), 1413-1417.
  • Poscia, A., Milovanovic, S., La Milia, D. I., Duplaga, M., Grysztar, M., Landi, F., ... & Ricciardi, W. (2018). Effectiveness of nutritional interventions addressed to elderly persons: umbrella systematic review with meta-analysis. The European Journal of Public Health, 28(2), 275-283.
  • Redley, B., Botti, M., Wood, B., & Bucknall, T. (2017). Interprofessional communication supporting clinical handover in emergency departments: An observation study. Australasian Emergency Nursing Journal, 20(3), 122-130.
  • Thürig, G., Schmitt, J. W., Slankamenac, K., & Werner, C. M. (2016). Safety of total hip arthroplasty for femoral neck fractures using the direct anterior approach: a retrospective observational study in 86 elderly patients. Patient safety in surgery, 10(1), 12.

Appendix: Scenario:

  • Mrs J is an 89-year-old lady with a diagnosis of Dementia. She lives alone in her family home. She had a fall three months ago and broke her right knee. She has been an inpatient for 13 weeks where she has been sent home with short-term carers coming to her house once daily. She has been recently readmitted to hospital due to another fall caused by a urinary tract infection (UTI), an unfortunate side effect of the treatment, as noted by the carers coming to her house.
  • Nursing staff have noted that Mrs J wanders at night; that she needs support to take her medication and with her continence. During the night, patients become very confused and require one-to-one assistance. The accident occurred at lunchtime in a bay of six patients where there was not enough staff during the shift due to a shortage. The nurse looking after the bay was called to the emergency buzzer to proceed with cardiopulmonary resuscitation (CPR) on another patient. The bay was left with a new staff member who joined the team recently and who has not been fully trained. The bay was left unattended and Mrs J fell to the floor as she tried to get out of bed, hitting her face heavily. The patient did not sustain any additional injuries other than bruises.
  • It was noted on admission that Mrs J was very disheveled and in a poor state physically. Her fingernails and toenails were very long and dirty and her hair was matted and unwashed. She was very underweight and dehydrated. She has no family that lives nearby, her husband died 10 years ago and she is estranged from her son.
  • When the Community Social Worker visited Mrs J's property, she noticed that Mrs J's home was in a very poor state. She had very little food in the house and the heating system did not appear to be working. Mrs J's washing machine was also broken and there were dirty clothes and dishes lying around in all of the rooms. There were many trip hazards around her home which was very cluttered.
  • Since being an inpatient, Mrs J has put on weight and, with Physiotherapy support, is able to walk short distances again. An Occupational Team assessment indicates that Jean requires support with all of her activities of living. The Community Social Worker, who is now allocated to Mrs J, has been told that Mrs J is now medically fit to be discharged from the hospital. She has assessed Mrs J's capacity to make a decision about her discharge destination. This choice to be made is between returning home with a QDS package of care (4 times daily) and moving into a supported living facility. The Social Worker has deemed Mrs J to lack capacity to make this decision on the basis that she does not feel that Mrs J could weigh up the information to make the decision. An Independent Mental Capacity Advocacy (IMCA) referral has been made, as Mrs J is unfriended. For the best interest of Mrs J, it has been agreed to send her into a care home as she was unsafe to be at home.
  • The Community Social Worker, who is now allocated to Mrs J, has been told that Mrs J is now medically fit to be discharged from hospital. She has assessed Mrs J capacity to make a decision about her discharge destination. This choice to be made is between returning home with a QDS package of care (4 times daily) and moving into a support living facility. The Social Worker has deemed Mrs J to lack capacity to make this decision on the basis that she does not feel that Mrs J could weigh up the information to make the decision. An Independent Mental Capacity Advocacy- IMCA referral has been made, as Mrs J is unfriended.
  • For the best interest of Mrs J it has been agreed to send her into a care home as she was unsafe to be at home.

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