Highlights
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 these 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
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”
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