09HDC01565 - Health and Disability Commissioner

Opinion 09HDC01565
The on-coming nurse did not ―go see‖ each patient immediately after report.
The issue of curtains around patients and the future use of more extensive monitoring
have been addressed by the CDHB. However I will comment about this further in my
report as it is significant in this case.
It appears that neuro observations including blood pressure, heart rate and temperature
were taken regularly. However the respiratory rate was not documented as taken.
Although sedation scores and the Glasgow Coma Scale were documented regularly,
this does not absolve the nurse from deliberately counting respirations. Although the
nurse states she heard [Mr A] snore at a regular rate, this does not tell us if the
respiratory rate was trending up or down which is how clinical judgment and decision
making is formulated. Respiratory rate (RR) is a sensitive and early predictor of
deterioration. RR is an expected parameter to measure and document on the following
CDHB forms: Early Warning Score; the adult Patient Controlled Analgesia (PCA)
Treatment Sheet & Record; the Neurological Observation Chart (QMRO 100); the
Drug Treatment Sheet for PRN drugs; and Neuroscience Documentation of Care. In
this case the nurses did not meet the expected standard of care (e.g. respiratory rate) as
required by the CDHB. The nurse has also failed to meet NZNO standards (1.10 &
1.11) which state the nurse provides documentation that meets legal requirements, is
consistent, effective, timely, accurate and appropriate; and uses competent clinical
judgment to implement all aspects of the nursing process, ensuring appropriate care.
In this case the nurse failed to assess the respiratory rate on [Mr A].
As well, the nurse did not meet NCNZ Code of Conduct (principle 2; criteria 2.4, 2.5,
2.9) which state the nurse demonstrates expected competencies in the practice area in
which currently engaged, upholds established standards of professional nursing
practice, and accurately maintains required records related to nursing practice. And
finally NCNZ Competencies (2.2, 2.3) for registered nurses state the nurse uses
suitable assessment tools and methods to assist the collection of data and maintains
clear, concise, timely, accurate and current client records within a legal and ethical
framework.
Clinicians know that RR is a strong predictor of potentially serious clinical events.
However even though the measurement of the RR requires no complex technology,
RR is the most difficult vital sign to obtain. ―Normal breathing is quiet and easy —
barely audible near the open mouth as a faint whish. When a healthy person lies
supine, the breathing movements of the thorax are relatively slight.‖ (Bickley, 2007).
Unlike blood pressure, pulse and temperature, to get an accurate RR one must closely
look for a place on the patient where breathing can be detected then count for at least
30 seconds to ensure an adequate count is made to determine irregularities in
breathing pattern and rate (Pirret, 2005). In the dark this is even more difficult. RR
monitoring takes deliberate attention and patience on the part of the clinician. It has
been noted to be the most neglected vital sign (Cretikos et al, 2008).
Although RR was not documented (and presumed not taken) falls short of the
expected standards, as noted above, the evidence provided forms a picture of a patient
being ―seen‖ every 2 hours (until 0500 hours) for a set of neuro observations. As well
57 5 September 2012
Names have been removed (except Canterbury DHB and the experts who advised on this case) to
protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the
person’s actual name.