Clinical Incident & Quality Improvement- Nursing Case Study

NRS30001: Clinical Incident & Quality Improvement- Nursing Case Study


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Events leading to Vanessa’s death.
Vanessa Anderson was born on the 11 th September 1989 and was 16 years of age at the time of her death. Vanessa resided with her parents, Warren & Michelle Anderson and her brother Nathan at 19 Mountview Parade, Hornsby Heights. Vanessa was a student at St Leo’s College at Wahroonga. Vanessa enjoyed good health the only
known medical condition being a history of asthma and allergies to nuts and shellfish. Vanessa was prescribed Ceratide and Ventolin for her asthma; she did not drink alcohol or smoke cigarettes. On Sunday 6 th November 2005, Vanessa was competing in a golf tournament at the Asquith Golf Club at Mount Colah and was playing in a team event. On the 5 th hole, after hitting her shot she walked in the direction of where she believed her ball was and while searching for her ball was struck by a golf ball on the right side of her head and behind her ear. This incident took place at 8.25am.

It is now known that Vanessa suffered a depressed fracture of her skull behind her right ear. Vanessa was conscious, but disoriented when she was first attended to by Ambulance officers on the golf course. Vanessa was conveyed to Hornsby Hospital where a scan was conducted. Vanessa had vomited several times on route and at the hospital. Vanessa was subsequently transferred to Royal North Shore Hospital where she was admitted and remained at that Hospital until her death some time in the early hours of Tuesday 8 th November 2005. This Inquest will focus primarily on the diagnosis and treatment of Vanessa during her period of hospitalisation at the Royal North Shore Hospital.

The Role of the Coroner.
It is important for the general public and particularly for the Anderson family to understand the role and function of a Coroner. The Coroner’s powers and responsibilities are those vested to him/her by Parliament by virtue of the provisions of the Coroners Act, 1980, as amended. A death is reportable to a Coroner when the death falls within the provisions of Section 13 of the Coroners Act. In Vanessa’s case, her death was a reportable death because she died suddenly, un-expectantly and in circumstances where a Doctor would be precluded from issuing a certificate as to the cause of death.

Vanessa’s death was reported to the office of the State Coroner, Glebe on the 9/11/2005, Constable Katrina Burrell being the reporting officer. I propose to outline a short chronology of the management and investigation of Vanessa’s death as it appears from the Glebe Coronial file and from my more recent involvement in the matter. I do this specifically as a number of criticisms have been made in regard to this investigation generally and more particularly assertions by certain parts of the media that I, as the presiding Coroner, have contributed to delays and have been
responsible for the Inquest being drawn out. As indicated above, Vanessa’s death was reported to the Senior Deputy State Coroner Glebe, Magistrate Milledge on the 9/11/2005. Her Honour directed that a post mortem examination be conducted and ordered a Police investigation and the preparation of a brief of evidence.

Relevant Facts established by the Evidence.
On the morning of Sunday 6 th November 2005, Vanessa Anderson was hit on the right side of head by a golf ball.
Vanessa was then taken by ambulance to Hornsby Hospital, where a CT scan was taken diagnosing her with a depressed focal skull fracture. Vanessa was reviewed by Dr Stephanie Moffatt, who telephoned Dr Azizi Bakar, Neurosurgical Registrar at Royal North Shore Hospital (‘RNSH”) regarding Vanessa’s transfer. Dr Moffatt was told by Dr Bakar to “hold Dilantin” until he could assess Vanessa at RNSH. Vanessa was transferred to RNSH at around 1pm that day. Dr Bakar who was employed as a neurosurgical fellow at RNSH, but in practice was doing a Registrar’s
duty diagnosed Vanessa as having a closed depressed right temporal skull fracture with temporal brain contusions. Dr Bakar classified Vanessa’s head injury as mild onthe basis of her Glasgow Coma Score (‘GCS”). Dr Bakar considered, but decided not prescribe for Vanessa anti-convulsant medication.

Building upon weekly activities undertaken in the tutorial sessions, this assessment task involves analysing the root causes of a clinical incident and identifying evidence based quality improvement strategies to prevent recurrence of the incident.

You will be paired with another student to undertake the root cause analysis (RCA) and prepare the RCA report. Each student in the pair will also be required to solely undertake the second component of the assessment task. Individuals marks will be awarded for the second component.

Please see the marking rubric which provides further detail on the paired and individual components.

To complete the report you will be required to:
Analyse an incident provided in week one the Black Board site
In your analysis identify the various causes that contributed to the clinical incident
Use an RCA template to analyse the incident and identify root causes.
After analysing the root causes of the incident, each student is to work individually to:
Identify action that could be taken to prevent recurrence of the event
Prioritise one nursing relevant strategy, and;
For your chosen strategy, draw upon available evidence to justify solutions or possible strategies to minimise the risk of recurrence of the incident

This evidence must be drawn from at least 5 peer-reviewed research papers, systematic reviews or evidence based clinical guidelines dated from 2010 onwards.

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