Iscipline of Nursing 4: Transition to Professional Nursing Practice

CLINICAL GOVERNANCE REPORT

Clinical Governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. It is about the ability to produce effective change so that high quality care is achieved.
A critical incident is usually an adverse event, where harm was caused to a patient, or a sentinel event involving mortality and significant morbidity.

TASK: To analyse the following critical incident and write a formal investigative report ( NOT AN ESSAY) to back up your recommendations for mitigation strategies, that if applied correctly, will result in preventing the recurrence of the incident:

106_sutherland.pdf

Use the following sub-headings:
1. Deviation from best practice (approx 500w)
2. Analysis (approx 500w)
3. Recommendations (approx. 1000w)

Your report requires you to:

Identify all the underlying/predisposing factors, their possible causes and how they lead to the adverse event. These root causes always form one or more chains of events. This process is often called root cause analysis (RCA) and requires you to look very carefully are what happened and look for root causes.

Conduct an effective literature search that finds appropriate evidence-based and peer reviewed literature to explain what should have happened. Compare and contrast what happened with what should have happened, had best practice been followed (dont use policy and procedure manuals or anecdotal evidence!).Do not use policies or procedures as literature sources unless you are critiquing them.

Explain in detail what needs to be done to prevent a similar adverse event from recurring. This requires you to provide peer reviewed evidence (research literature) to back up your recommendations and is critical to the report. Any recommendation that is not backed up with appropriate research literature will not be accepted as relevant.

Compare and contrast the various aspects of the incident, including the outcomes with EVIDENCE BASED PRACTICE, i.e what should have taken place according to current research literature.
Identification and analysis of the various factors that were considered to have led to the incident; this is also referred to as root cause analysis. E.g how did each factor specifically lead to the incident and its outcome(s)? Were there any relationships between the factors and if so what were they?

*** IMPORTANT: Analysis of these factors must be by means of PATIENT SAFTEY MODEL: Helmreich Musson Model

Detailed recommendations of how the factors identified could be controlled or eliminated and prevented from leading to the same outcome(s). This should be written objectively and targeted to advise and inform other colleagues and executive.

*** ALL resources used must be appropriate evidence-based and peer reviewed literature, Australian, and no more than 5 years old. ***