The Garling Report (2008) highlighted, amongst others, details the critical incident and death of a 16-year-old girl, Vanessa Anderson in 2005. Watch the ABC video and read the coroners’ report found on the Interprofessional Education for Quality Use of Medicines (IPEQUM) website below.
After watching the video read the following questions and post them into the forum (150 words)
1. What are the key clinical governance issues that surfaced here?
2. Why are these issues significant? ( please do not answer these questions)
Below are 2 answers and 2 replies already to these questions. Please use one of the following discussions for the 500 word report either forum post 1 or 2.
The key clinical governance matters in which arose from the coronial findings that the initial patient assessments, monitoring for deterioration, incompetent staff, missing patient files, ward resources, staffing, documentation and communication all contributed to the death and severity of the case of Vanessa Anderson. Communication was one of the ongoing key findings from the corona in which the junior medical doctor, registrar and admitting doctor was incoherent, limited and inconclusive to which was consequential in the life of Vanessa.
These issues are significant due to the recognition of deterioration and the lack of communication using the chain of command to raise clinical concerns could have changed the outcome of Vanessa to receive appropriate care. The administration of the analgesics of Morphine, Tramadol and 30mg of Endone were not questioned by administrative nursing staff nor consulted by the admitting doctor. The ongoing pain and patient complaints of not being able to move were not managed, documented nor passed on to further treating doctor. These issues were not managed within a timely manner as the deterioration was evident.
Consider the Registered Nurse Standards for Practice. How should an RN have responded in such a situation to promote safe patient outcomes?
I agree with Olivia’s assessment that that the lack of communication between multiple health professionals was a major clinical governance issues that was identified in Vanessa’s coronial findings. Along with a number of other clinical governance failures, which played a part in Vanessa’s death.
The Registered Nurse Standards for Practice are a set of criteria, which Registered Nurse are required to follow. These standards must be demonstrated by Registered Nurse not only during clinical care of a patient, but also in any role they utilise their nursing “knowledge and skills”.
Through her actions or lack thereof, the nurse in charge did not demonstrate a number of the Standard of Practice in the following ways. The nurse was concerned about the dosage of codeine administered to Vanessa but did not raise this concern with the doctor that prescribed it. By not raising this concern with the doctor, the nurse did not contribute to providing safe and quality care to Vanessa or advocate on her behalf. By not doing so, this did not uphold standards 1 or 2. Standard 1, being “thinks critically and analyses nursing practice” and standard 2, being “engages in therapeutic. The nurse in charge also did not report concerns made by Vanessa about not being able to move to other staff or document this in Vanessa’s medical notes. A medical review should have been called about this concern and other staff notified. By not doing so, this nurse did not uphold standards 4, 5 or 6. These standards being “comprehensively conducts assessments”, “develops a plan for nursing practice” or “provides safe appropriate and responsive quality nursing practice”.
Assessment instructions
After all discussions have been conducted each student is to complete a 500 word report based on of the discussion for each of the topics. Your report should focus the discussion that has interested you and assisted with your awareness and knowledge on the topic of discussion.
In this report, you are to:
• Identify the key points of the discussion topics.
• Discuss the differing ideas presented by your team in each topic.
• Analyse your experience from participating in the discussion and how this has impacted on your understanding of leadership and change.
