NUR3605: Leadership, Governance and Culture

Assignment Task

 Task 

The assessment instructions have been designed to enable you to understand what is required to succeed in this assignment.

The aim of this Assignment is to show your understanding of the process by which sentinel events are reviewed and learning occurs - making way for improvements in the future. The process of completing this assignment will consolidate your understanding of quality improvement methodology.

Step 1: Read the attached From Death We Learn – Opioid toxicity. Note that this is an incomplete replication of the original as we want you to come up with your own ideas and actions.

Step 2: Use a systematic approach to review the case and identify possible causes of the event. Determine two main themes or situational factors that you wish to address in the following steps. In the appendix show the systematic approach you took to review the case and the findings you made.

• In your discussion of this event, you are NOT required to make professional or clinical care recommendations in regard to the actions of the nurses/health care workers involved.

Step 3: Based on your findings in step two, review relevant literature to determine what should have occurred in this scenario, noting if there were gaps in practice or deviations from best practice guidelines in relation to the two areas you wish to focus improvements on.

Step 4: Discuss the case in relation to what you have found in step 3

Step 5: Using a quality methodological approach recommend two actions, supported by literature that could be implemented for a change in practice to circumvent such events recuring.

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