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NUR3201: Quality, Safety and Risk Management Plan on Coroners Report Assessment 2
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Assessment 2
Digital Literacy and Communication Skills
Questions for Analysis:
- How did the lack of digital communication tools contribute to the adverse outcome in RJH's case?
- What digital tools could have been used to facilitate better communication and decision-making?
- How can digital literacy be improved among healthcare professionals to enhance patient safety?
Clinical Governance and Risk Mitigation
Questions for Analysis:
- What lapses in clinical governance were evident in the coroner's findings?
- How can clinical governance be strengthened to prevent similar incidents?
- What role does leadership play in promoting a culture of safety and quality?
Risk Management Legislation and Guidelines
Questions for Analysis:
- What legislation, regulations, or guidelines were not adhered to in RJH's case?
- How can compliance with these regulations be ensured in clinical practice?
- What policies and procedures should be implemented to align with legal requirements?
National Safety and Quality Health Service Standards and Aged Care Quality Standards
Questions for Analysis:
- How did the failure to adhere to safety and quality standards contribute to the adverse outcome?
- What specific standards were breached in this case? Consider RN standards of practice
- How can adherence to these standards be improved in healthcare settings?
Clinical Reasoning and Critical Thinking
Questions for Analysis:
- How did lapses in clinical reasoning and critical thinking contribute to the adverse outcome?
- What training or strategies can enhance clinical reasoning and decision-making skills?
- How can interprofessional collaboration improve clinical reasoning and patient outcomes?
Principles of Quality, Safety, and Risk Management
Questions for Analysis:
- What principles of quality, safety, and risk management were not followed in RJH's case?
- How can continuous improvement be promoted in healthcare practice?
- What strategies can be implemented to foster a culture of safety and quality?
Assessment Requirements Brief Summary
Assessment 2: Digital Literacy and Communication Skills focuses on critically analysing a coroner’s case (RJH) through the lens of quality, safety, and risk management in healthcare. The assessment requires students to apply theoretical knowledge to a real-world adverse outcome and evaluate failures in systems, communication, governance, and clinical practice.
The key areas covered in the assessment include:
- Digital Literacy and Communication Skills
- Analysis of how inadequate digital communication contributed to the adverse outcome
- Identification of digital tools that could have improved communication and decision-making
- Strategies to enhance digital literacy among healthcare professionals to improve patient safety
- Clinical Governance and Risk Mitigation
- Identification of governance failures highlighted in the coroner’s findings
- Recommendations to strengthen governance frameworks
- Evaluation of leadership’s role in fostering safety and quality culture
- Risk Management Legislation and Guidelines
- Identification of relevant legislation, regulations, and guidelines not followed
- Strategies to ensure compliance in clinical practice
- Development of policies and procedures aligned with legal requirements
- National Safety and Quality Health Service (NSQHS) Standards and Aged Care Quality Standards
- Analysis of breaches in safety and quality standards
- Consideration of RN standards of practice
- Strategies to improve compliance with national standards
- Clinical Reasoning and Critical Thinking
- Examination of how poor clinical reasoning contributed to the adverse outcome
- Identification of training strategies to enhance decision-making
- Role of interprofessional collaboration in improving patient outcomes
- Principles of Quality, Safety, and Risk Management
- Identification of key principles not followed
- Strategies to promote continuous quality improvement
- Methods to foster a strong culture of safety and accountability
Step-by-Step Approach Guided by the Academic Mentor
The academic mentor adopted a structured and supportive approach to guide the student through each component of the assessment.
Step 1: Clarifying Assessment Expectations
The mentor began by explaining the purpose of the assessment—linking theoretical concepts of quality, safety, and risk management to a real coroner’s case. The marking criteria were reviewed to ensure the student understood the importance of critical analysis rather than description.
Step 2: Case Understanding and Issue Identification
The student was guided to carefully review RJH’s case and extract key facts, timelines, and failures. The mentor helped the student identify where communication breakdowns, governance issues, and clinical decision-making lapses occurred.
Step 3: Section-by-Section Analysis
Each assessment section was addressed individually:
- For digital literacy, the mentor helped link communication failures to missing or underutilised digital tools.
- In clinical governance, the student analysed leadership gaps and systemic weaknesses using coroner findings.
- For legislation and standards, relevant healthcare regulations and NSQHS standards were mapped directly to breaches in the case.
- In clinical reasoning, the mentor guided reflective and evidence-based analysis of decision-making failures.
- For quality and risk management, the focus was placed on continuous improvement and safety culture strategies.
Step 4: Integrating Evidence and Standards
The mentor ensured that national standards, RN standards of practice, and legislation were explicitly referenced and clearly connected to the analysis, strengthening academic rigor.
Step 5: Developing Recommendations
The student was supported in proposing realistic, practice-based strategies for improvement, including digital solutions, governance reforms, staff training, and policy implementation.
Step 6: Review and Refinement
The final step involved refining clarity, coherence, and academic tone. The mentor ensured all questions were fully addressed and that critical thinking was consistently demonstrated.
Outcome Achieved
Through this guided approach, the student successfully produced a well-structured and critical assessment that:
- Clearly linked theory to practice
- Demonstrated strong analytical and clinical reasoning skills
- Addressed all assessment questions comprehensively
- Applied relevant legislation, standards, and governance frameworks
Learning Objectives Covered
- Critical evaluation of healthcare failures and adverse outcomes
- Application of digital literacy concepts in clinical settings
- Understanding of clinical governance and leadership roles
- Interpretation of healthcare legislation and national standards
- Development of clinical reasoning and interprofessional awareness
- Promotion of quality, safety, and risk management principles
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