What happened:

1. A routine operation – a patient story
2. Prioritisation
3. Graded assertiveness – breaking the hierarchy
4. Communication methods, techniques
5. Projects (cqi quality improvement projects)
6. Tools
7. Situational awareness

So what?

1. I will not retell the patient story, as it will not do justice to the event. You need to hear it for yourself. I will tell you this. The patient story of a routine operation alarms and horrifies me. It outlines a breakdown of basic communication yet highlights the impact of a hierarchical regime. The nurses did not question or were assertive however were able to in an instant identify the core of the issues at present. The failure: to intubate and ventilate resulting in catastrophic patient death. The nurses were able to identify a crisis yet felt restrained or were not assertive enough to to act. Despite regulations and procedures in place for this type of catastrophic event, they… Continue reading →

What happened-

– today l heard and learnt about:

1. The story of Lewis Blackman
2. Implications of diagnostic errors
3. Premature closure or anchoring
4. The importance of transparency in health
5. Mindfulness
6. Communication
7. The importance of open communication with the patient and family

So what?

1. Lewis’s story is so distressing because I have seen this happen multiple times before. The ongoing saga of issues associated with this has lead to multiple reviews and recognisable changes in the healthcare system to provide a “safety net” for acceptable “parameters”. The issue with this is the evidence behind the decisions making processes. Lewis’s story has allowed me to reflect on issues I have observed in the past and the frustration I have experienced as both a junior and senior member of the nursing team. This story demonstrates multiple failures and, with the benefit of hindsight we are able to form a clear picture of the… Continue reading →