Discuss Extensively the Swiss cheese effect of contribution of poor communication, clinical handover, medication safety and clinical assessment in the case.
Discuss Extensively the Swiss cheese effect of contribution of poor communication, clinical handover, medication safety and clinical assessment in the case.
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The Task
The death of Vanessa Anderson
Discuss Extensively the Swiss cheese effect of contribution of poor communication, clinical handover, medication safety and clinical assessment in the case.
“As Deputy State Coroner for the past six years I have regrettably presided over many inquests involving deaths in hospitals. In many of these cases one error or omission sometimes a serious one led to death, however, I have never seen a case such as Vanessa’s in which almost every conceivable error or omission was detected and those errors continued to build one on top of the other? Magistrate Milanovich 24/1/2008. Westmead Coroners Court. NSW.
Standard 4 of the Registered Nurse standards for practice stipulates (the Nursing and Midwifery Board of Australia, 2016, p4) that “RNs will accurately conduct comprehensive and systematic assessments. They analyse information and data and communicate outcomes as the basis for practice.? Discuss the case of Vanessa Anderson. Your essay should include discussion of the following points:
?The human factors focusing on communication that led to the adverse outcomes in this case.
?The coroner’s findings in relation to systems improvement and communication errors and how these errors became a catalyst for change.
?The role of the RN in the detection and reporting of clinical deterioration.
?The contributing factors in Vanessa death, focusing on the Coroners findings and the recommendations that resulted from the Coroner’s Inquest and the Garling report.
Support your discussion with particular focus on the academic literature surrounding the contributory factors of communication, patient safety, clinical handover and medication safety.
Planning
An academic paper uses the following features: This paper requires you to read the associated literature surrounding Vanessa Anderson’s death identify key contributing factors as highlighted by the coroner and support your findings with information from the academic literature in relation to these findings.
?An introduction (approximately 10% of the suggested word
?A body (approximately 80% of the suggested word count)
?A conclusion (approximately 10%of the suggested word count)
?Read the question carefully and identify the main areas that you will be required to research.
?Read the reports and watch the videos associated with Vanessa’s death.
?Identify the coroner’s recommendations.
?Research the areas the coroner highlighted and base your academic research on these areas.
Writing your paper.
Once you have completed your assignment plan, use it to write your assignment with A minimum of 20 references used including 1 journal article as well as a relevant book and/or web site. The plan should include citation details for each key point. Your final assignment should contain grammatically correct sentence structure, paraphrasing and in-text citations. A reference list should be included at the end of your paragraph using APA referencing style. Your assignment should include at least 20 references from quality sources.
Links for your use are-
https://www.ipeforqum.com.au/modules/vanessa-anderson/
https://www.abc.net.au/7.30/content/2007/s2146037.htm
https://www.smh.com.au/news/national/how-system-fatally-failed-vanessa/2008/01/24/1201025048650.html
https://en.wikipedia.org/wiki/The_Garling_Report
https://www.dailytelegraph.com.au/news/nsw/drug-ordered-for-dead-girl/story-e6freuzi-1111113338132
https://www.dailytelegraph.com.au/news/nsw/apology-for-death-insult/story-e6freuzi-1111115893272
https://www.theaustralian.com.au/archive/news/coroner-blames-hospital-for-death/story-e6frg6o6-1111115395031
https://www.mja.com.au/journal/2008/188/8/royal-north-shore-hospital-inquiry-analysis-recommendations-and-implications
https://www.news.com.au/national/how-vanessa-andersons-father-helped-laura-van-baarle/story-e6frfkp9-1111117988503
https://www.palmerlegal.net.au/#!coronial-inquests/clt8
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