NUR3201- Quality Safety and Risk Assessment

Assessed Course Learning Outcomes

CLO 1, 2, 3, 4, 5, 6, 7

Rationale

By critically analysing the coroner's case in relation to the seven course learning objectives, you will gain a deeper understanding of the importance of integrated risk management, digital literacy, clinical governance, adherence to legislation, safety standards, clinical reasoning, and continuous improvement in healthcare. This knowledge, combined with practical application to a real-life clinical case, will equip you with the skills necessary to manage risk in your future practice as a Registered Nurse.

Task Instructions

This Risk Management Plan requires you to critically analyse the non-inquest findings into the death of ELR, published by the Coroners Court of Queensland on July 26th, 2023.

You will integrate this analysis with the seven course learning objectives related to quality, safety, and risk management in healthcare, incorporating relevant standards, legislation, and contemporary peer-reviewed literature in your responses.

1. Integrated Risk Management in Inter-Professional Healthcare (250 words)
Questions for Analysis:

• What were the key risk factors identified in the coroner's findings?

• How could these risks have been better identified and managed through inter-professional collaboration?

• What strategies can be implemented to mitigate similar risks in the future?

2. Digital Literacy and Communication Skills (250 words)
Questions for Analysis:

• How did the lack of digital communication tools contribute to the adverse outcome in the ELR case?

• What digital tools could have been used to facilitate better communication and decision-making?

• How can digital literacy be improved among healthcare professionals to enhance patient safety?

3. Clinical Governance and Risk Mitigation (300 words)
Questions for Analysis:

• What lapses in clinical governance were evident in the coroner's findings?

• How can clinical governance be strengthened to prevent similar incidents?

• What role does leadership play in promoting a culture of safety and quality?

• Synthesise relevant literature into your response.

4. Risk Management Legislation and Guidelines (300 words)
Questions for Analysis:

• What legislation, regulations, or guidelines were not adhered to in the ELR case?

• How can compliance with these regulations be ensured in clinical practice?

• What policies and procedures should be implemented to align with legal requirements?

• Include reference to policy/legislative guidelines.

5. National Safety and Quality Health Service Standards and Aged Care Quality Standards (300 words)
Questions for Analysis:

• How did the failure to adhere to safety and quality standards contribute to the adverse outcome?

• What specific standards were breached in this case? Consider RN standards of practice.

• How can adherence to these standards be improved in healthcare settings?

• Refer to the NSQHS Standards and relevant guidelines/policy and literature to support your response.

6. Clinical Reasoning and Critical Thinking (300 words)
Questions for Analysis:

• How did lapses in clinical reasoning and critical thinking contribute to the adverse outcome?

• What training or strategies can enhance clinical reasoning and decision-making skills?

• How can interprofessional collaboration improve clinical reasoning and patient outcomes?

• Synthesise relevant literature into your response.

7. Principles of Quality, Safety, and Risk Management (300 words)
Questions for Analysis:

• What principles of quality, safety, and risk management were not followed in the ELR case?

• How can continuous improvement be promoted in healthcare practice?

• What strategies can be implemented to foster a culture of safety and quality?

• Utilise relevant literature and evidence-based practice to support your response.

Assessment Requirements Summary

The assessment required students to prepare a Risk Management Plan critically analysing the non-inquest findings into the death of ELR, published by the Coroners Court of Queensland. The aim was to link the case analysis to the seven course learning outcomes (CLO 1–7), focusing on quality, safety, and risk management in healthcare.

Key pointers to be covered included:

• Integrated Risk Management : Identifying key risk factors and strategies for inter-professional collaboration.

• Digital Literacy and Communication : Evaluating how digital communication tools could improve patient safety.

• Clinical Governance and Risk Mitigation : Analysing lapses in governance and leadership roles in promoting safety.

• Legislation and Guidelines : Understanding legal frameworks and compliance strategies.

• National Safety and Quality Standards : Linking the case to NSQHS and Aged Care Quality Standards.

• Clinical Reasoning and Critical Thinking : Examining decision-making and inter-professional problem-solving.

• Principles of Quality, Safety, and Risk Management : Applying continuous improvement strategies to promote a culture of safety.

Students were expected to integrate relevant literature, legislation, policy guidelines, and clinical standards to support their analysis.

Assessment Approach by Academic Mentor

The Academic Mentor guided the student through a step-by-step structured process, ensuring clarity and alignment with the assessment objectives:

1. Familiarisation with Case

   • The mentor encouraged the student to thoroughly read the ELR coroner’s report.

   • Key risk factors, lapses in governance, and procedural errors were highlighted as initial discussion points.

2. Section-Wise Analysis

   • Integrated Risk Management : The mentor guided identification of inter-professional risk factors and strategies for mitigation.

   • Digital Literacy and Communication : Students explored the impact of inadequate communication tools and identified digital solutions to improve safety.

   • Clinical Governance : Lapses were analysed, and literature on leadership and quality culture was integrated.

   • Legislation and Guidelines : Compliance gaps were mapped against relevant policies and legal frameworks.

   • Safety Standards : NSQHS and Aged Care Standards were linked to observed case failures.

   • Clinical Reasoning : Strategies to improve critical thinking and collaborative decision-making were outlined.

   • Quality, Safety, and Risk Principles : Continuous improvement strategies were applied to reinforce a culture of safety.

3. Integration of Literature and Evidence

   • The mentor guided the student to synthesise peer-reviewed literature and link it directly to each section, ensuring evidence-based responses.

   • References to legislation, policies, and standards were embedded where appropriate.

4. Draft Review and Feedback

   • Stepwise review of each section allowed the student to refine arguments, ensure clarity, and align with word counts.

   • Feedback focused on linking theory to practice and addressing all CLOs comprehensively.

Outcome and Learning Objectives Achieved

• The final Risk Management Plan presented a structured, evidence-based analysis of the ELR case.

• The assessment successfully covered all seven CLOs: integrated risk management, digital literacy, clinical governance, legislation, safety standards, clinical reasoning, and principles of quality and safety.

• The student developed critical thinking, analytical skills, and applied knowledge of healthcare risk management, preparing them for safe, effective professional practice as a Registered Nurse.

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