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.
Please use this case
This website will be helpful
(remember that this essay is for the registered nurses not for midwifery.
After reading the case study Please answer the Questions.
Q 1. 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 patients
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
Q.2 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 terms 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
Q.3 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 could this adverse event 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
Remember to structure as an essay – starting with an introduction and conclusion
Often it is easier to come back and write the introduction last – they can be tricky to start
Don’t include any new information in your conclusion – sum up your discussion
Formal writing – use formal words and avoid slang or personal terms – unless you are quoting from your case (make sure to indicate if you are doing this)
Write in the 3rd person – avoid personal terms like “I” think – this should be objective writing (not subjective – which is your opinion)
Spelling – this should be Australian spelling – so make sure your spellcheck is set for this and not US spelling
Don’t forget to use in-text references to back up your discussion in the last section
Headings – you can use headings to structure your essay to line up with the questions asked if you would like – however remember your essay should still flow and these should not be presented as discrete answers – they must link together – otherwise this will pull down marks.
