Mrs Bentley, an 84 years-old was admitted to hospital for a routine total knee replacement (TKR). Mrs Bentley was alert and oriented before surgery, chatting with the nursing team and her pre-op observations were all within normal limits. Mrs Bentley’s surgery commenced at 1700hrs, two hours later than planned due to a complication with the previous patient in the theatre. The tired OT staff rushed to prepare for Mrs Bentley’s surgery and all the instruments were checked by Scrub RN Nicole, who quickly looked over the trays of instruments and stapled the paper instrument receipts from Clean Sterile Supply Department (CSSD) in the patients notes. Mrs Bentley’s surgery was uneventful, and she was transferred to post anaesthetic care unit (PACU). She recovered well, and the only issue was a slightly elevated temperature. The PACU nurse reasoned that this was probably due to post-op inflammation and noted this on the PACU report. Mrs Bentley was transferred to the orthopaedic ward at 1930hrs, where she was received by RN Steve. Steve completed a set of initial post-operative observations, noting Mrs Bentley’s elevated temperature. Steve missed some scheduled post-op observations on Mrs Bentley as he was busy. When the night shift arrived at 2100hrs Steve handed over to RN Misha that Mrs Bentley was stable, had not passed urine since her return to the ward and her temperature remained elevated due to post-op inflammation, but it had been like this since PACU so was not reason for concern. Misha did a set of observations noting that Mrs Bentley still had a high temperature, her BP was a bit low and she gave Mrs Bentley an extra blanket as she was shivering. Mrs Bentley seemed a bit sleepy and confused to Misha, but Misha thought that this was normal considering Mrs Bentley’s age and documented “temp due to inflammation, low BP, wound dressing dry and intact, confused dementia” in Mrs
Bentley’s notes. The night shift was very busy due to two staff calling in sick so Misha didn’t
do any further observations on Mrs Bentley, only checking on her as she walked past the
room noting that Mrs Bentley appeared to be sleeping.
When the morning shift arrived at 7am Mrs Bentley was found semi-conscious, disoriented,
moaning in pain. Her skin was clammy, and there was purulent ooze from her operation site.
The MET team were called, and Mrs Bentley was transferred to ICU, where she was placed
on assisted ventilation. She was also administered a large dose of IV antibiotics for
suspected infection and had to return to theatre for further surgery to remove the infected
prosthesis. She eventually recovered after a long hospital stay but had ongoing health
issues. During the Infection Prevention and Control follow-up of Mrs Bentley’s critical
AUSTRALIAN CATHOLIC UNIVERSITY 2024
NRSG378
1
incident it was noted that two of the trays of instruments used in Mrs Bentley’s surgery were
not sterile with the CSSD tickets in her notes stating "steriliser cycle incomplete”.
The root cause of this incident was that surgery was performed with unsterile
instruments.
1. Discussion of identified root cause
Briefly discuss how the identified root cause has led to the outcome for the patient.
2. Identification and discussion of contributing factors
Discuss three (3) contributing factors which have likely led to this sentinel event.
3. Links to NMBA RN Standards for Practice
Identify and discuss two (2) separate NMBA RN Standards which were not practiced or maintained by the nurse(s) involved in this sentinel event, that may have led to the identified root cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not just standard 7).
4. Links to National Safety and Quality Health Service (NSQHS) Standards
Identify and discuss two (2) separate NSQHS Standards which were breached (or not met) in this scenario, that may have led to the identified root cause. You need to identify and discuss specific actions items (e.g. Clinical Governance Standard, action 1.03).
5. Recommendations
Outline three (3) recommendations to address the contributing factors you identified from the chosen case study (from question 2), or the root cause. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations.
Recommendations to address contributing factors or root cause Practical example(s) to achieve recommendations Position responsible/ accountable

Question

munushrestha4 munushrestha4

22-04-2024
Health

Answered

Mrs Bentley, an 84 years-old was admitted to hospital for a routine total knee replacement (TKR). Mrs Bentley was alert and oriented before surgery, chatting with the nursing team and her pre-op observations were all within normal limits. Mrs Bentley’s surgery commenced at 1700hrs, two hours later than planned due to a complication with the previous patient in the theatre. The tired OT staff rushed to prepare for Mrs Bentley’s surgery and all the instruments were checked by Scrub RN Nicole, who quickly looked over the trays of instruments and stapled the paper instrument receipts from Clean Sterile Supply Department (CSSD) in the patients notes. Mrs Bentley’s surgery was uneventful, and she was transferred to post anaesthetic care unit (PACU). She recovered well, and the only issue was a slightly elevated temperature. The PACU nurse reasoned that this was probably due to post-op inflammation and noted this on the PACU report. Mrs Bentley was transferred to the orthopaedic ward at 1930hrs, where she was received by RN Steve. Steve completed a set of initial post-operative observations, noting Mrs Bentley’s elevated temperature. Steve missed some scheduled post-op observations on Mrs Bentley as he was busy. When the night shift arrived at 2100hrs Steve handed over to RN Misha that Mrs Bentley was stable, had not passed urine since her return to the ward and her temperature remained elevated due to post-op inflammation, but it had been like this since PACU so was not reason for concern. Misha did a set of observations noting that Mrs Bentley still had a high temperature, her BP was a bit low and she gave Mrs Bentley an extra blanket as she was shivering. Mrs Bentley seemed a bit sleepy and confused to Misha, but Misha thought that this was normal considering Mrs Bentley’s age and documented “temp due to inflammation, low BP, wound dressing dry and intact, confused dementia” in Mrs
Bentley’s notes. The night shift was very busy due to two staff calling in sick so Misha didn’t
do any further observations on Mrs Bentley, only checking on her as she walked past the
room noting that Mrs Bentley appeared to be sleeping.
When the morning shift arrived at 7am Mrs Bentley was found semi-conscious, disoriented,
moaning in pain. Her skin was clammy, and there was purulent ooze from her operation site.
The MET team were called, and Mrs Bentley was transferred to ICU, where she was placed
on assisted ventilation. She was also administered a large dose of IV antibiotics for
suspected infection and had to return to theatre for further surgery to remove the infected
prosthesis. She eventually recovered after a long hospital stay but had ongoing health
issues. During the Infection Prevention and Control follow-up of Mrs Bentley’s critical
AUSTRALIAN CATHOLIC UNIVERSITY 2024
NRSG378
1
incident it was noted that two of the trays of instruments used in Mrs Bentley’s surgery were
not sterile with the CSSD tickets in her notes stating "steriliser cycle incomplete”.
The root cause of this incident was that surgery was performed with unsterile
instruments.
1. Discussion of identified root cause
Briefly discuss how the identified root cause has led to the outcome for the patient.
2. Identification and discussion of contributing factors
Discuss three (3) contributing factors which have likely led to this sentinel event.
3. Links to NMBA RN Standards for Practice
Identify and discuss two (2) separate NMBA RN Standards which were not practiced or maintained by the nurse(s) involved in this sentinel event, that may have led to the identified root cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not just standard 7).
4. Links to National Safety and Quality Health Service (NSQHS) Standards
Identify and discuss two (2) separate NSQHS Standards which were breached (or not met) in this scenario, that may have led to the identified root cause. You need to identify and discuss specific actions items (e.g. Clinical Governance Standard, action 1.03).
5. Recommendations
Outline three (3) recommendations to address the contributing factors you identified from the chosen case study (from question 2), or the root cause. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations.
Recommendations to address contributing factors or root cause Practical example(s) to achieve recommendations Position responsible/ accountable

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