A Critical Incident Analysis in Midwifery Care

Introduction:

In this assignment, I will be using pseudonyms when referring to the clients (my practice supervisor, my patient and the trust). This will ensure that confidentiality is maintained and protecting my colleague’s personal information (NMC, 2018). I will be referring to the client as Mrs ABC, my practice supervisor as Mentor X and the Trust will be referred to as Trust A. My mentor Mr. X and I were handed over Mrs. ABC, from the (allocated) day shift midwifery. She was admitted to the delivery and labour department with spontaneous rapture of membrane (SROM). Mrs. ABC a Nulliparous woman was in her 41 weeks gestation, with a high-risk pregnancy has gestation diabetes and pervious venous thromboembolism (VTE).

The preliminary assessment indicated that Mrs ABC was well and all of her vitals were in normal range. Mrs ABC's background information was complete and helpful, and it didn't indicate any prior complications. Soon after the handover from Day shift midwife, the delivery took place, it was spontaneous vaginal delivery (SVD) without any further complications, and Mrs ABC was fine after giving birth to a girl. After the delivery, the senior midwife in charge came around to assess the situation. She realised that mentor X filled the client's documents (birth notes) inappropriately. The content sticker for the name, date of birth and NHS numbers was missing which is considered unacceptable as this information is vital and should be on every health record page (Gear, 2015).

My mentor was instructed to apply stickers including delivery time and birth weight to all the relevant documents and pages by the senior midwife in charge. This was to ensure accuracy and avoid issues of missing and incorrectly filled information (The Royal College of Midwives (RCM), 2021). Necessary actions were taken and additional notes were noted in the records, however I noticed that mentor X had not used the correct timestamps for the delivery and the infant feeding time as my previous notes did not match her records.

In an effort to correct the errors, I shared my notes with my mentor but resisted claiming that the information I presented was already useless as she had already filled out the documents. I thought her actions were not up to the NMC code because she must ensure that the records are complete and accurate without falsification (RCM, 2020). However, everything else was maintained the NMC code; entries were made in Black ink, correcting fluid as well as jargons and offensive statements were not used, which made it very easy to understand (Rowe, 2019).

From the above audit I was able to learn the value and the role of maintaining the NMC code of conduct in protecting the health and well-being of the general public by ensuring accurate record are kept and set standards of conduct are maintained to ensure performance is improved. This audit emphasizes on the clear and transparent process of investigating the midwives and nurses who fall short of the NMC standards and codes of conduct. In the context of nursing, record keeping is important as it provides the correct account of treatment and care administered to patients which helps in identifying problems that arise and the specific actions undertaken to correct them(Mutshatshi et al, 2018).

References

Basic Clinical Record Keeping Standards. NHS. Retrieved 2 April 2021 fromhttps://www.bfwh.nhs.uk/wp-content/uploads/2015/08/413_Health-Record-Procedure.pdf

Mutshatshi, T. E., Mothiba, T. M., Mamogobo, P. M., & Mbombi, M. O. (2018).

Record-keeping: Challenges experienced by nurses in selected public hospitals. Curationis, 41(1), 1-6. https://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S2223-62792018000100014

Rowe, G. (2019).

PRACTISING VALUES AND ETHICS IN HEALTH AND CARE SETTINGS. The Handbook for Nursing Associates and Assistant Practitioners, 75.

https://books.google.co.ke/books

The Nursing and Midwifery Council. (2018).

The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC. Retrieved 3 April 2021 from https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

The Royal College of Midwives. (2021).

Record Keeping. RCM. Retrieved 3 April 2021 from https://www.rcm.org.uk/media/4818/rcm_guidance-report_elec_record_keeping.pdf

Trust A. (2021).

Maternity department. NHS. Retrieved 23 March 2021 from https://www.westhertshospitals.nhs.uk/maternity/givingbirth/.

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