TopicStudents must choose an adverse event (AE) or near-miss case that they have experienced....

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TopicStudents must choose an adverse event (AE) or near-miss case that they have experienced. Students will then present their analysis of this real case with their interpretation on the application of safety and quality in clinical practice based on principles of evidence-based care.The presentation should include the following 6 parts:1. A ief description of the AE and the contributing factors.2. Potential or actual financial costs resulting from the AE3. Expected actions and accountability of the staff involved4. An analysis of the AE using Root Cause Analysis or the Swiss Cheese Model of analysis5. A discussion on the significance of each of the following elements and how they may have contributed to the AE:    6.     · Communication· The hospital environment· Latent factors· Equipment· System baiers· Rules· Policies and procedures· Fatigue· Rosters6. A discussion of one of the following strategies with a description of how it might have prevented or reduced the impact of the AE:    7.     · Tools for disclosure.· Open Disclosure (EAR principle)· ‘Just’ culture.· Safety and Quality Policies.· Safety and Quality Research.· Evidence Based Practice.· Ten tips for patients and clinicians (Safety and Quality Commission).· Risk Ratings· The 10 national standards; measures of S&Q for healthcare.The presentation must be referenced as per the school’s academic manual. Additional supporting information to be discussed in the presentation is to be included in the notes section of the PowerPoint.A timetable will be distributed to all students.Students are required to provide the course coordinator with an electronic copy of their presentation the Friday before the week of presentations, to enable the smooth running of the day. Please be punctual, respectful and attentive to your fellow students. TopicStudents must choose an adverse event (AE) or near-miss case that they have experienced. Students will then present their analysis of this real case with their interpretation on the application of safety and quality in clinical practice based on principles of evidence-based care.The presentation should include the following 6 parts:1. A ief description of the AE and the contributing factors.2. Potential or actual financial costs resulting from the AE3. Expected actions and accountability of the staff involved4. An analysis of the AE using Root Cause Analysis or the Swiss Cheese Model of analysis5. A discussion on the significance of each of the following elements and how they may have contributed to the AE:    6.     · Communication· The hospital environment· Latent factors· Equipment· System baiers· Rules· Policies and procedures· Fatigue· Rosters6. A discussion of one of the following strategies with a description of how it might have prevented or reduced the impact of the AE:    7.     · Tools for disclosure.· Open Disclosure (EAR principle)· ‘Just’ culture.· Safety and Quality Policies.· Safety and Quality Research.· Evidence Based Practice.· Ten tips for patients and clinicians (Safety and Quality Commission).· Risk Ratings· The 10 national standards; measures of S&Q for healthcare.The presentation must be referenced as per the school’s academic manual. Additional supporting information to be discussed in the presentation is to be included in the notes section of the PowerPoint.A timetable will be distributed to all students.Students are required to provide the course coordinator with an electronic copy of their presentation the Friday before the week of presentations, to enable the smooth running of the day. Please be punctual, respectful and attentive to your fellow students. TopicStudents must choose an adverse event (AE) or near-miss case that they have experienced. Students will then present their analysis of this real case with their interpretation on the application of safety and quality in clinical practice based on principles of evidence-based care.The presentation should include the following 6 parts:1. A ief description of the AE and the contributing factors.2. Potential or actual financial costs resulting from the AE3. Expected actions and accountability of the staff involved4. An analysis of the AE using Root Cause Analysis or the Swiss Cheese Model of analysis5. A discussion on the significance of each of the following elements and how they may have contributed to the AE:    6.     · Communication· The hospital environment· Latent factors· Equipment· System baiers· Rules· Policies and procedures· Fatigue· Rosters6. A discussion of one of the following strategies with a description of how it might have prevented or reduced the impact of the AE:    7.     · Tools for disclosure.· Open Disclosure (EAR principle)· ‘Just’ culture.· Safety and Quality Policies.· Safety and Quality Research.· Evidence Based Practice.· Ten tips for patients and clinicians (Safety and Quality Commission).· Risk Ratings· The 10 national standards; measures of S&Q for healthcare.The presentation must be referenced as per the school’s academic manual. Additional supporting information to be discussed in the presentation is to be included in the notes section of the PowerPoint.A timetable will be distributed to all students.Students are required to provide the course coordinator with an electronic copy of their presentation the Friday before the week of presentations, to enable the smooth running of the day. Please be punctual, respectful and attentive to your fellow students.

Taruna · Accepted Answer

The Failure of Communication 
A Case Study of Adverse Event 
The Failure of Communication 
Introduction 
In today's health care climate, delivering quality patient care is a challenge. 
Even with the many advancements in simple , efficient, interpersonal communication in technology , the process of sending and receiving information between two or more individuals is interpersonal communication. 
At times, there are gaps in the delivery of message or sharing of the information which leads to negative conclusions. 
Communication deficiencies have been cited as the leading cause of inadvertent patient damage. Failures in communication include problems such as inadequate information, erroneous sharing of existing information, vague and contradictory information, and lack of timely and efficient sharing of patient information.
2
Introduction Contd.
Thanks to the fact that it can be used in a number of different contexts in various clinical environments, 
it is a valuable method for both verbal and non-verbal forms of communication. It helps, in my view, to break the real and perceived barriers between clinical staff and enables the understanding that because of the use of this universal model, contact between staff from different areas should be of a high standard and easily shared.
When looking at workers at work in a busy ward setting, and how it can be difficult at times and even miscommunicated to pass on information between, for example, the doctor and nurse, it makes it clear to me that systematic use of communication tools can lead to better patient health and safety and should be standard practise in all clinical circumstances.
3
Case Study 
A 35-year-old woman with painful, irritated skin on both the right and left sides of her face and forehead came to the clinic. 
In particular, signs of inflammation around the nasal-labial fold and perioral region and around the buccal and frontal areas were identified. 
Within a day after obtaining aesthetic treatment at the clinic, she found the problem.
To reduce the signs of lines and wrinkles in the frontal, buccal and nasal-labial regions, she received a course of dermal filler injections containing Restylene. She may experience some soreness and redness, although she was warned, the patient was not aware of the type of active substances in her dermal fillers.
4
Case Study( the gap) 
She was also not offered a number of treatment options and she did not receive any after-care leaflets. 
In particular, she had red, swollen and painful skin when she smiled or spoke. 
Three days after her operation, the patient entered the clinic where she was examined by her aesthetic nurse.
There were some visible gaps in the communication so far; her first requirement was to receive the after care leaflets which were not given to her. Thu, she had not awareness about her further course of care.

Topic Students must choose an adverse event (AE) or near-miss case that they have experienced. Students will then present their analysis of this real case with their interpretation on the application...

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