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.
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.