Easy ( Based on Real Case )

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Identify a case from the NSW Nurses and Midwives’ Board or HCCC, Caselaw or AHPRA website which involved a registered nurse(s) who had their registration cancelled or suspended for greater than 6 months due to their involvement in an adverse event for a patient in their care.

· Access the following websites and choose a case that fits the description above (see highlighted terms) and that interests you.

https://www.hccc.nsw.gov.au/Hearings---decisions/Default

https://www.nursingmidwiferyboard.gov.au/News.aspx

https://www.ahpra.gov.au/Publications/Tribunal-Decisions.aspx

https://www.caselaw.nsw.gov.au/browse-court/54a634063004de94513d828a

NB: You need to provide the reference number and link to the case (the full case not a summary) – your assessment cannot be marked without it

NB: If your case involves more than 1 RN you can discuss them all in your essay

THEN structure your assignment to include the following information

What actions/omissions on the part of the Registered Nurse(s) contributed to the adverse outcome for the patient

· Actions – what did the RN(s) DO that contributed to the adverse event e.g. administer the wrong medication

· Omissions – what did the RN(s) NOT DO that contributed to the adverse event e.g. failed to report a deteriorating patient

· Don’t just provide a dot point list – please structure this information in essay format.

· If there are a number of items to discuss you may want to group them together under headings and provide examples e.g. failure to complete observations on patient as required – the RN did not record any observations during their 12-hour shift for the patient

NB: you do not need to provide references here - you have already told us which case you are reporting on

Were there any other factors (e.g. systems-based) that contributed to the adverse outcome for this patient?

· Were other factors listed as also contributing to this adverse event for the patient e.g. actions/omissions of other healthcare staff

· “System-based errors” are often implicated in adverse events – make sure you understand what this term means

· Systems-based errors are different from human-based errors – the actions/omissions of the RN(s) would be human-based errors

· Systems based errors can include things like skills mix, ratios, mixing adults and children on the same ward, equipment not in working order

· I have uploaded an article to give you some more background on this topic

· HINT: if you think there aren’t any other factors – ask yourself if the RN(s) made these errors (actions and/or omissions) – how did they go unnoticed and lead to an adverse event? How were they allowed to happen?

· NB: you do not need to provide references here - you have already told us which case you are reporting on

With reference to the evidence-based literature (including relevant NSW policies) outline the actions that should have been taken by the Registered Nurse(s) to prevent the adverse outcome for the patient.

· This is essentially asking how this adverse event could have been avoided

· This should follow on logically from your discussion in the previous sections

· This should align with the information you provided in section 2 of your essay

· What actions did the RN(s) take that they should not have and what should they have done?

· What omissions did the RN(s) take (what didn’t they do that they should have) and what should they have done

· What guidelines currently exist that tell us what to do in this situation? E.g. NSW Health policies, local protocols, guidelines

· How would the correct actions have changed the outcome for the patient e.g. deterioration would have been picked up and care escalated

· For the higher marks look beyond policies to the evidence in the topic e.g. if your patient died as a result of deterioration not being picked up – there is a body of evidence focused on the deteriorating patient

· The evidence is the rationale for the actions you are recommending – the “why”

NB: This section does require evidence – remember if you don’t reference your work it reads just like your opinion on something and this will pull your mark down

Conclusion