Assessment 3 – Clinical Scenario with structured questions Assessment Type Case Study / Problem Based Learning Description You have learned about error in health care and the implications for clinical governance in health care organisations. Many of you will be familiar with the various programs and approaches used to manage risk and respond to incidents in health care organisations. For this assessment: Describe a clinical situation you have experienced where there was an adverse event that resulted in a poor outcome for a patient (300 words). Please de-identify this description do not use names of people or health care facilities. My experience is with a person 80 years who ended up with aspiration Pneumonia on and off because care staff are not watching her when she eats, so she was sent to hospital and was on IV Clindamycin for a few days, got a little better and was sent back to us in the nursing home, Dr reviewed her a requested to continue on clindamycin liquid 10mls 4 times a day for 7days. She couldnt cope she ended up deteriating and dying. Use this link to access and view this video: https://www.youtube.com/watch?v=YeSvCEpg6ew (Second Victim) video Respond to the following questions in relation to the clinical situation identified above. Use sub-headings to identify each of the questions in your response. 1. Describe the short term and long term impact of this clinical situation on the staff (second victims) involved in the event, in their professional roles and personal lives. 2. As an advanced practice nurse or nurse practitioner: describe the role and responsibilities of unit managers and senior clinicians who may be involved in responding to individual staff involved in an adverse event. What do these staff need in the aftermath of the event? 3. As an advanced practice nurse or nurse practitioner: Consider the impact of the event on team dynamics, communication, trust and perceived competence in the context of the organisational culture at that time. 4. What organisational reporting and/or investigation would be required in response to an event like this? What external reporting and/or investigation would be required in response to an event like this? 5. How should health care organisations support health professionals involved in adverse events? How should these organisations support health professionals during investigations of adverse events? Is there a need for clinical supervision following an adverse event? 6. How can second victims contribute to the prevention of adverse events? References Wu AW. (2000). Medical error: the second victim: The doctor who makes the mistake needs help too. British Medical Journal, 320 (7237),726-727. NURS6120: Contemporary Nursing WebLearn GradSchool Trimester 2 – 2016 Page 8 of 14 Scott S, Hirschinger L, Cox K, McCoig M, Brandt J, Hall L. (2009). The natural history of recovery for the healthcare provider ‘second victim’ after adverse patient events. Quality and Safety in Healthcare, 18:325-330. Scott SD, Hirschinger LE, Cox KR. (2008). Sharing the load of a nurse “second victim”. Rescuing the healer after trauma. RN, 71(12):38-43. Sirriyeh R, Lawton R, Gardner P, Armitage G. (2010). Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Quality and Safety in Health Care, 19(e43):1-8. Treiber L, Jones J. (2010). Devastatingly human: An analysis of registered nurse’s medication error accounts. Qualitative Health Research, 20(10):1327-1342. Denham C. (2007). TRUST: The 5 Rights of the second victim. Journal of Patient Safety, 3(2):107-119. Santomauro C, Kalkman C, Dekker S. (2014). Second victims, organisational resilience and the role of hospital administration. Journal of Hospital Administration, 3(3):95-103 Weighting 35% Compulsory Requirements Attempt / Submission Requirement – Students must attempt/submit this assessment item to pass the course. Length 1,400 Words Due 1 August
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