critical incident

critical incident

Order Description

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. It requires clinicians and administrators to take joint responsibility for making sure this occurs.
A critical incident can be any of the following:
o an adverse event (where ‘harm’ was caused to a patient or colleague),
o a sentinel event, death (involving mortality and significant morbidity), or
All critical incidents result from a series of underlying/predisposing factors resulting usually from human error, and deficiencies in systems and processes or procedures. When a series of factors line up in a certain way, an adverse event results. If the sequence of events is correctly analysed, the investigator can identify its origin and key points in the sequence, this allows the investigator to design mitigation strategies that can effectively stop that same sequence from recurring.
The task in this assignment is to:
Write a ‘Formal Investigative Report’ about a real-life critical incident that has occurred.
The student should use a critical incident that has been published on the Internet or via any other public domain.
Please use the below as a guide of what to include in this report, the marking criteria will also help guide you.
Introduction/Background to the Incident: A short introduction including what the report is about followed by a brief background to the critical incident.
Data: Critically examine the case to identify and explore all the predisposing factors that lead to the outcome, these factors are the ‘root causes’. This information needs to be supported by a flow chart with annotations to present the complex details of the incident in an easy to view format.
Analysis: Analysis of the information presented in the ‘data’ section can be referred to as a ‘root cause analysis’ (RCA). The predisposing factors are explored in regards to why they existed and how they lead to the incident. Any relationships between the factors is also explained. Use a ‘patient safety model’ diagram to demonstrate the factors that were the root causes that lead to the incident and to identify factors that if mitigated would have prevented the incident from occurring.
NB: Root causes always form one or more chains of events. If a RCA is conducted correctly it will lead you back to the origin of this chain of events. If you can eliminate one or more of the root causes or break the chain of events you can prevent the same type of adverse event from recurring. A patient safety model is a conceptual construct that guides the investigator in the process of analysis.
Discussion: In this section of the report current evidence-based peer reviewed literature is explored in relation to the incident and the root causes of the incident to develop a deeper understanding of the why the incident occurred, what should have happened and how it could be prevented in the future. The ANMAC competencies should be discussed in relation to professional best practice with two (2) relevant competencies being explored further. The literature discussed needs to be of a high quality and be current.
Recommendations: Evidence-based recommendations are made, which if implemented correctly would prevent the same incident from occurring again. Literature which supports the recommendations needs to be presented, otherwise the report will have little credibility. Any recommendations must address the identified pre-disposing factors, in particular the ‘root causes’ and explain how the recommendations will mitigate these factors using a clear and logical approach.

STATE CORONER’S COURT
OF NEW SOUTH WALES

Inquest: Inquest into the death Luke Wood
Hearing dates: 20 – 24 October 2014
Date of findings: 19 November 2014
Place of findings: State Coroner’s Court, Glebe.
Findings of: Magistrate Sharon Freund,
Deputy State Coroner
File numbers: 2011/390507

Findings: I find that Luke Wood died on 31 August 2011 at Westmead
Hospital as a result of an intraperitoneal haemorrhage from an
anastomotic leak from a transplanted renal artery.

Recommendations The Director-General of the Ministry of Health
that consideration be given to the development of a policy or
protocol for the timely provision of all medical records to the
coroner when a death is notified pursuant to s.6(1) (b) and (e)
of the Coroners Act 2009

Representation: Mr P Griffin instructed by Ms M Heris, solicitor, Crown
Solicitor’s Office, as Counsel Assisting;
Mr M Ayache, solicitor, of One Group Legal, for the family of
Luke Wood;
Mr S Woods instructed by Henry Davis York, solicitors for
Western Sydney Local Health District and Doctors Gupta,
Fedderson, Ali and Muralitharan;
Mr C Jackson instructed by MDA National for Dr Thwaites.
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FINDINGS
Luke Wood was just 35 years old when he passed away at Westmead Hospital
(“Westmead”) eleven days after he had undergone a kidney transplant operation in that same hospital.
Luke is survived by his parents Marie and Bernard, fiancé Nora, brother Adam and
sisters Joanne and Danielle. His death has left those that loved and knew him clearly
struggling to understand why an apparently healthy and fit young man left them so
unexpectedly. Luke known as “Moose” to his brother Adam, and “Big Luke” to those in the body building community, was described to me as a caring man who was larger than life and who always put others first. Adam spoke on the final day of the inquest and gave me some insight into his “little” big brother, their bond was evident from those first words and it is clear that Adam was proud of his brother’s achievements and Luke appreciated his brother’s advice and mentoring. Nora, Luke’s fiancé, also bravely spoke of the loss of her soul mate on the inquest’s final day. Luke’s death was only eight weeks before their wedding, all their plans and dreams for the future ended on that evening of 31 August 2011. Both Adam and Nora spoke so eloquently and gave me much personal insight into the man, son, brother and fiancé known with awe and great fondness as “Big Luke Wood”.
Luke was, until he retired in 2009, a professional body builder and achieved domestic and international success in this competitive and demanding field. In 1996, when he was just 20 years old, he won the Australian International Federation of Body Builders (“IFBB”) Junior Title and two years later he became the youngest competitor to be granted Professional Status by the IFBB. He won the Australian championship on six occasions. Luke also competed in international events and was so highly regarded that he received a personal invitation from Arnold Schwarzenegger to compete in the Arnold Classic in Columbus, Ohio.
In about 2008, Luke underwent testing at Liverpool Hospital that revealed that he had an enlarged heart and that his kidneys were not functioning at anywhere near their optimal capacity. The advice Luke initially received was that he would not need to undergo dialysis.
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However, eighteen months later, in March 2010, Luke was referred by his GP to Dr
Mark Penny, a nephrologist at St Vincent’s Hospital. Dr Penny’s diagnosis of Luke’s
kidney problems revealed that the situation was more serious than originally assessed. Luke began to see Dr Penny on a monthly basis and he was also treated regularly by Dr Newman, a cardiologist.
In January 2011, on a referral from Dr Penny, Luke began regular dialysis at the
NephroCare Bondi Dialysis Centre. It is at about this time that investigations began
about the possibility of a kidney transplant and in July 2011 Luke was placed on the
kidney transplant list at Westmead.
On 19 August 2011 a suitable kidney became available and Luke was admitted to
Westmead for the purposes of a transplant.
On 20 August 2011, a three hour kidney transplant operation was performed by Dr
Vincent Lam assisted by Dr Stephen Thwaites. The usual surgical procedure was not modified due to Luke’s musculature and the procedure was reported to be uneventful.1
On 23 August 2011, three days after the surgery, early signs of rejection emerged. A
renal biopsy was performed under ultrasound guidance by a transplant physician. This procedure was not documented in the progress notes. However, it was documented in the “kidney transplant progress sheet” (“Flow Sheet”),2 which I note was only produced by Westmead on the second day of the inquest.
Thereafter, on 24 August 2011, thymoglobulin an anti-rejection drug was administered to counter the organ rejection.
On 25 August 2011, five days after the surgery, the nursing staff observed and recorded marked bruising of Luke’s abdominal wall, scrotum and thighs. A plain non-contrast CT scan of his abdomen was conducted and revealed that the fluid collection shown was 1 Exhibit 1, Tab 15, paragraphs 13-15; and Tab 22, paragraphs 8-10;
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most likely to be blood. However, the evidence from Dr Thwaites was that the Doctors were satisfied at this time that there was no active bleeding.3
Luke was discharged from Westmead on 26 August 2011 and commenced daily
outpatient care to monitor his recovery.
On 27 August 2011, Luke saw Dr Moses at the outpatient clinic and his swelling and
bruising was assessed.
The notes from the outpatient clinic,4 and the Flow Sheet,5 indicate that Luke attended the outpatient clinic daily after he was discharged from Westmead on 26 August 2011.
These records indicate there was nothing untoward in his progress at this time. Despite this, at about 1pm on 31 August 2011, eleven days after his surgery, Luke reported severe abdominal pain and became unconscious. Upon regaining consciousness he vomited and had diarrhoea. The pain was reported to extend from his chest to his legs.
He was taken by ambulance to Westmead.
The ambulance records state that:6 “Transplant Team requested pt t/port to Westmead
Hosp”. Luke arrived at the Emergency Department of Westmead at approximately
2:55pm.7 Thereafter, he was seen and treated by a number of medical practitioners
from the emergency department, intensive care and renal transplant team.
Ultimately, at 9.05pm, approximately six hours after his admission into the Emergency Department, Luke was taken to the operating suite for an emergency laparotomy. At 9.51pm, Drs John and Mohammadieh commenced Luke’s anaesthesia. Upon intubation, Luke immediately developed a sinus tachycardia with a loss of palpable pulse. Metaraminol was administered, but Luke went into bradycardic arrest. CPR and blood transfusions were commenced. At 10.35pm, Dr Tran, the consultant anaesthetist arrived and conducted a transthoracic echocardiogram and then a transoesophagael echocardiogram. Those tests identified that there was no evidence of cardiac 3 Oral evidence of 21/10/14 and Exhibit 1, Volume 1, Tab 22, paragraphs 16-18;
4 Exhibit 1, Volume 2, Tab 27;
5 Exhibit 5;
6 Exhibit 1,Volume 2, Tab 27D;
7 Ibid – the ambulance records indicate that Luke was triaged at this time and was off the stretcher at
3:10pm;
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tamponade, no myocardial activity and marked ventricular hypertrophy. It is
uncontroversial that despite requesting Luke’s medical records from his transplant
surgery prior to the commencement of the emergency laparotomy, those records were never received.
At 11.15pm, the planned laparotomy was conducted by Dr Lam, the consultant
transplant surgeon and Dr Thwaites, transplant surgery fellow. A large amount of intraabdominal fluid was discovered. Manual compression of the aorta was commenced, however the doctors were unable to locate any obvious bleeding site, although a possible site in the venous anastomosis was sutured.
CPR was unsuccessful and Luke was pronounced dead at 11.40pm on
31 August 2011.
The role of a Coroner, as set out in s. 81 of the Coroners Act 2009 (“the Act”), is to
make findings as to:
1. the identity of the deceased;
2. the date and place of a person’s death;
3. the physical or medical cause of death; and
4. the manner of death, in other words, the circumstances surrounding the death.
A Coroner, pursuant to s.82 of the Act, also has the power to make recommendations,
which concern any public health or safety issues arising out of the death in question.
There is no issue in relation to the identity, date, place or exact cause of Luke’s death.
The issues for this inquest arise solely out of the surrounding circumstances of his
death as set out by Mr Griffin, Counsel Assisting in his opening address. They are:
1. Were the care and treatment provided to Luke in the Emergency Department of
Westmead on 31 August 2011 adequate?
2. Were the manner and form of anaesthesia administered to Luke at Westmead
on 31 August 2011 appropriate? and
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3. Are there any recommendations that ought be made, arising from the care and
treatment provided to Luke at Westmead on 31 August 2011?
I shall deal with each of the issues in turn.
However, before doing so I think it prudent to comment, so far as it is relevant, on
Luke’s use of steroids. Luke was a professional body builder who trained intensively
and abided by a strict diet however, his extreme musculature was consistent with the
use of steroids. Luke did admit to the use of steroids to at least some of his treating
medical practitioners.
Dr Margaret Stark, the Director of the Clinical Forensic Medicine Unit of the NSW Police Force provided an expert statement dated 15 March 2013.8 Her evidence can be summarised as follows:
1. Anabolic and androgenic steroids (“AAS”) and performance and image
enhancing drugs (“PIEDS”) are listed as prescribed restricted substances under
the Poisons and Therapeutic Goods Act 1966;
2. It is illegal to possess AAS without a prescription in Australia;
3. Polypharmacy, namely usage of more than one drug, is common in AAS and
PIEDS users for the side effects of the steroids, for example use of diuretics to
counteract fluid retention and tamoxifen to reduce gynaecomastia;
4. Individuals may take steroids by injection or orally and will use doses that
exceed therapeutic level;
5. Chronic usage may affect the heart causing enlargement – myocardial
hypertrophy and cardiomyopathy – and cause an increase risk of thrombosis,
and abnormalities in the blood lipids. There may also be abnormal liver function
and formation of liver cysts and/or cancerous tumours.
8 Exhibit 1, Tab 23;
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As stated by Counsel Assisting at the outset, this inquest was not about the use and
abuse of steroids. However, during the investigation undertaken in preparation for the inquest, some of the independent medical experts consulted by the Court were asked whether steroid use and Luke’s extreme musculature were relevant factors in relation to his care and treatment. Expert opinion received for this inquest revealed inter alia that such use would not have impacted on Luke’s suitability for the kidney transplant surgery. 9 There was also evidence before me that high protein diets and anabolic steroid use are known risk factors for developing chronic renal failure.10 I also note that Luke had focal and segmental glomerulosclerosis (“FSGS”) and that his high protein diet and hypertension would have accelerated his progression toward end stage renal failure.11

WAS THE CARE AND TREATMENT PROVIDED TO LUKE FOLLOWING HIS
KIDNEY TRANSPLANT ON 20 AUGUST 2011 ADEQUATE?
While the care and treatment provided to Luke prior to his admission to the Emergency Department on 31 August 2011 was not formally an issue for consideration at the commencement of the inquest, it is a matter that was averted to in the preparation of this matter for hearing, including with respect to initial expert opinions obtained.
In particular, Professor Steve Chadban, Nephrologist and Transplant Physician, was
engaged by the Court to provide an expert opinion regarding the care and treatment
Luke received. His report is dated 30 June 2013.12 He also gave oral evidence on the
third day of the inquest. He concluded that the post-operative inpatient care received by Luke, including his discharge on 26 August 2011 was appropriate.13
Following his discharge on 26 August 2011, Luke received outpatient care by way of
daily attendance at the Westmead Transplant Clinic in order to monitor his recovery and progress. Professor Chadban opined inter alia that being seen daily by a consultant physician and a nurse “represents very adequate care”.14
9 Exhibit 1, Volume 1, Tab 24, pages 1 – 3 – Expert opinion of Professor Steve Chadban;
10 Dr Vincent Lam – Exhibit 1, Volume 1, Tab 15, paragraph 11;
11 Professor Steve Chadban – Exhibit 1, Volume 1, Tab 24, paragraph 15;
12 Exhibit 1, Volume 1, Tab 24;
13 Ibid at page 3, paragraphs 3-5 inclusive;
14 Ibid, at page 4, paragraph 7;
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Luke’s family, were reportably (and understandably) particularly distressed by the
extensive bruising and alleged inadequacy of his pain management. However, the
overwhelming evidence received by this inquest was that the bruising was consistent
with the nature of the surgery and Luke’s extreme musculature. The treating
practitioners and the experts expressed a shared view that the pain management was, in the circumstances, appropriate, especially as it was determined and calibrated by pain management experts, and reviewed and adjusted as necessary.
Accordingly, I am satisfied on the balance of probabilities that the care and treatment
received by Luke was adequate whilst he was both an inpatient and outpatient,
immediately following his kidney transplant surgery.
WAS THE CARE AND TREATMENT PROVIDED TO LUKE ON 31 AUGUST 2011, IN
THE EMERGENCY DEPARTMENT OF WESTMEAD ADEQUATE?
Luke was last examined by Dr Nankivell in the Transplant Clinic on the morning of 31
August 2011. The evidence of Dr Nankivell was that Luke’s post-operative recuperation was progressing in accordance with expectations and that Luke “looked in the best condition since the transplant operation”.15
Upon re-admission the sequence of events was complicated by the fact that
practitioners from different teams were involved in his assessments and decisions in
relation to his care and treatment.
Prior to Luke’s arrival at the Emergency Department, the transplant team at Westmead had been notified of Luke’s condition and requested that he be transported directly to their hospital16. Additionally, the evidence indicates that Dr Thwaites, the transplant surgical fellow that had assisted in Luke’s transplant operation eleven days earlier, had been informed that Luke was returning to Westmead because he was unwell and had abdominal pain17.
15 Exhibit 1, Volume 1, Tab 22B, paragraph 9;
16 Exhibit 1, Volume 2, Tab 27D;
17 Exhibit 1, Volume 1, Tab 22, paragraph 20;
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Upon arrival, Luke was triaged as Category 2 and seen by Dr Muralitharan, Emergency Registrar. The evidence indicates that Dr Muralitharan saw Luke within five minutes in the Emergency Department as he attended where the ambulance was taking Luke off the stretcher and placing him on the hospital bed. Whilst Dr Muralitharan was present with Luke, members of the renal transplant team, namely Doctors Ali and Ng arrived.
This occurred no later than 3:40pm but possibly earlier.
Doctor Ali at the time was an advanced trainee in nephrology. He had prior knowledge of Luke and had seen Luke post-transplant when he was still an inpatient, and also once in the outpatient clinic. It was the evidence of Dr Ali, inter alia, that during his review of Luke, in the Emergency Department, he discussed the case with Dr Nankivell over the phone. Dr Nankivell was one of the consultants involved in Luke’s treatment, and had seen Luke both prior to, and post, surgery.
Thereafter, Dr Thwaites, Transplant Surgery Fellow, proactively attended the
Emergency Department at about 5:00-5:30pm, to ascertain what was happening with
Luke’s care. He was then advised by Dr Fedderson that Dr Nankivell had been
consulted and a CT scan had been ordered. Dr Thwaites then contacted the radiology department to effectively “chase up” the CT scan and its results. He was informed that Luke was currently undergoing the CT scan, so Dr Thwaites waited by a computer so he could immediately access the results.
The unequivocal opinion of Professor Fulde, Professor in Emergency Medicine, and
independent expert retained by the Court, is that the transplant team should have
assumed responsibility for Wood even though he was a patient in the Emergency
Department. Mr Woods, Counsel for Westmead, submitted that that is exactly what
happened. That is true, however, it was also the view of Professor Fulde that the care and treatment of Luke, a complex patient lacked “consultant involvement” from the “very beginning” of his care and that as a result opportunities were missed. While giving oral evidence Professor Fulde expressed a view to the effect that it is well known that the sooner a more senior person is involved, the better the patient outcome. He also expressed the view that a more senior practitioner has the experience and clout within an hospital setting to appropriately prioritise patients, and their individual requirements, in accordance with a clear command structure. In this matter, Professor Fulde was Page | 10
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unable to identify a clear command structure, or anyone who had primary carriage of
Luke’s care and treatment.
Similarly, Professor Chadban opined that patient management from after the triage
stage to when he was taken to theatre “appears to have lacked urgency and consultant input”.18 In evidence on 22 October 2014, Professor Chadban acknowledged the timing of certain facts and treatment that was more favourable to the Westmead staff.
However, he ultimately did not resile from his opinion.
It is true that Dr Ali liaised with with Dr Nankivell and that Dr Thwaites was advised of
Luke’s pending arrival to the Emergency Department. However, at no point during the first one and a half to two hours after Luke’s admission to the Emergency Department, did a consultant on the Renal Transplant Team attend to Luke personally or chase up the results of the CT scan which were highly significant as to the ultimate course of his treatment and its timeliness. Accordingly, I am satisfied on the balance of probabilities that unfortunately, although adequate, there were some missed opportunities in relation to Luke’s care and treatment. However, I am also of the view that had these opportunities been seized, it is unlikely the ultimate outcome would have changed at the end of the day.

WERE THE MANNER AND FORM OF ANAESTHESIA ADMINISTERED TO LUKE AT WESTMEAD HOSPITAL ON 31 AUGUST 2011 APPROPRIATE?
Clinical Associate Professor Ross MacPherson, the Senior Staff Specialist, Department of Anaesthesia and Pain Management, Royal North Shore Hospital, provided an expert report in relation to anaesthetic issues dated 1 July 2014.19
Professor MacPherson was not required for cross-examination.
His report responded to a series of questions, most of which specifically related to
anaesthesia. In summary he concluded that the level of care provided to Luke in the
Emergency Department at Westmead was appropriate.20
18 Exhibit 1, Volume 1, Tab 24, page 4, pt.9;
19 Exhibit 1, Volume 1, Tab 25A;
20 Exhibit 1, Volume 1, Tab 25A, Page 1, Q1;
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He identified various risks and challenges in respect to the administration of
anaesthesia arising from Luke’s renal problems such as:
1. difficulties with venous and arterial access;
2. electrolyte imbalance;
3. anaemia;
4. fluid balance; and
5. drug metabolism.
Professor MacPherson discussed each of these issues and concluded that they were adequately addressed by the anaesthetists who attended Luke on
31 August 2011.
None of the testimony of the other witnesses called to give evidence challenged the
conclusions of Professor MacPherson. Accordingly, I am satisfied on the balance of
probabilities that the manner and form of anaesthesia administered on 31 August 2011 were appropriate.
ARE THERE ANY RECOMMENDATIONS ARISING FROM THE CARE AND
TREATMENT PROVIDED TO LUKE AT WESTMEAD HOSPITAL ON 31 AUGUST
2011?
On 31 August 2011 those treating Luke were unable to gain access to medical records relating to him as they were locked in the transplant unit room in a separate part of the hospital.
This was of particular concern to those responsible for administering the anaesthetic
during the proposed emergency surgery.
It was fortunate that the available surgeons, namely Doctors Lam and Thwaites had
personal knowledge of his recent transplant surgery – but even this familiarity is no
substitute for being able to consult the complete records. The expert evidence is that
even if these records were available it is unlikely that the ultimate outcome would have
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been different. However, it is a fundamental principle that relevant records should be
accessible.
A secondary issue that became relevant during the course of this inquest was the
provision of relevant medical records by Westmead to this Court. Despite numerous
subpoenas and correspondence between the Crown Solicitor and those representing
Westmead, and enquiries made by the officer in charge, documents clearly significant and relevant to the treatment of Luke were not provided to the Court until during the actual hearing. The failure to provide the medical records in a timely manner caused distress to the family and unhelpfully fuelled conspiracy theories by those who loved and cared for Luke on the basis that those treating him were trying to cover up some wrong doing. This was ultimately not the case and the delay in the provision of the documents was explained, but it came at a price.
Finally, following Luke’s untimely death, Westmead conducted a root cause analysis,
which made various recommendations. A table of all current outstanding
recommendations, provided by Westmead, was provided to the Court. 21 It indicates that all but one of the recommendations have been implemented.
The recommendation to which there is no evidence of implementation relates to the
management of issues resulting from extreme bodybuilding. It envisages providing
information to the Ministry of Health and the Coroner “for advice and propagation”.
[Item 11035.2].
The subject matter of many of the recommendations that have been implemented is
identical to matters that have been examined in this inquest. Whether the changes
made have been efficacious is beyond the scope of this inquest.
21 Exhibit 1, Tab 26;
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Dimension High Distinction Distinction Credit Pass
Report structure and presentation
(Possible marks 5) Marks 4-5
The report is logically presented with clear and concise professional language.
The use of effective flowcharts or diagrams which easily demonstrate the intended information and enhance the report.
The report adheres to the presentation requirements in the Subject Outline.
Overall the report is excellently written with a systematic and logical presentation and would be suitable for publication. Marks 3- 4
The report is systematic and utilises professional language.
Flow charts and diagrams are used which are easy to interpret and linked to the report.
The report adheres to the presentation requirements in the Subject Outline.
The report is well written and set out at the level of an investigative report. Marks 2.5-3
The report is clearly structured and aligns with the table of contents.
A flow chart or diagram has been used which is relevant and can be interpreted easily.
The report adheres to the presentation requirements in the Subject Outline.
The report is well written with no spelling or grammar errors. Marks 2.5
The report has some structure.
A diagram or flow chart is used and labelled but could be linked to the report better
The report mostly adheres to the presentation requirements in the Subject Outline.
There are few spelling, grammatical or formatting errors.
Introduction & background of the critical incident
(Possible marks 10) Marks 8-10
The introduction is clear, concise and gives a logical overview of the issue and what will be discussed.
The background to the critical incident is clear and concise with a clear summation of the events and outcome. Marks 7-8
The introduction is clear, concise and gives a logical overview of the issue and what will be discussed.
The background to the critical incident clearly outlines the events and outcome. Marks 6-7
The introduction introduces the critical incident and gives an overview of what will be discussed.
The background to the critical incident is outlined. Marks 5-6
The introduction gives an overview of what will be discussed but lacks clarity and has some formatting errors.
The background to the critical incident is lacking in the main points or has been poorly summarised.
Data
(Possible marks 10) Marks 8-10
A clear and concise but comprehensive description of all the factors leading to the critical incident enhanced by an exceptional flow chart which clearly demonstrates the complex details of the incident in a easy to understand format. Marks 7-8
A comprehensive description of the factors leading to the critical incident enhanced by a well designed flow chart which clearly demonstrates the complex details of the incident in a easy to understand format. Marks 6-7
A clear description of the main factors leading to the critical incident enhanced by an flow chart which clearly demonstrates the complex details of the incident in a easy to understand format. Marks 5-6
A superficial description of the factors leading to the critical incident with a flow chart that demonstrates these factors. The flow chart may be of poor quality or may be difficult to interpret.
Analysis
(Possible marks 10) Marks 8-10
Insightful and logical interpretation of all the factors that were the root causes that lead to the incident.
Inter-related factors identified.
Interpretation of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which clearly demonstrates the findings and displays a high level of logical thought. Marks 7-8
Logical interpretation of the factors that were the root causes that lead to the incident.
Interpretation of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which clearly demonstrates the findings. Marks 6-7
Interpretation of the factors that were the root causes that lead to the incident.
Identification of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which demonstrates the findings. Marks 5-6
Identification of the factors that were the root causes that lead to the incident.
Minimal interpretation of the data.
A patient safety model is used to demonstrate the findings, however this may be difficult to interpret or be of a poor quality.
Discussion
(Possible marks 15) Marks 13-15
Comprehensive and logical exploration of the main root causes of the incident in relation to current evidence based best practice guidelines and 2 relevant and well related ANMAC competencies.
High quality literature is explored to discuss the root causes in relation to other similar cases. Marks 11-13
Logical exploration of the main root causes of the incident in relation to current evidence based best practice guidelines and 2 relevant ANMAC competencies.
High quality literature is used in the discussion. Marks 9-11
Exploration of the root causes of the incident in relation to current best practice guidelines and 2 relevant ANMAC competencies.
High quality literature is used in the discussion. Marks 7.5- 9
Discussion of the root causes of the incident in relation to current best practice guidelines and 2 ANMAC competencies is limited.
Acceptable literature is used in the discussion.
Recommendations
(Possible marks 10) Marks 8-10
All recommendations are clearly and concisely presented and logically and comprehensively linked to the predisposing factors and mitigation strategies.
Recommendations are achievable and if implemented would prevent the same type of incident occurring again.
High quality literature used expertly to support the recommendations. Marks 7-8
All recommendation are clearly presented and coherently linked to the predisposing factors and mitigation strategies.
Recommendations are achievable and if implemented would prevent the same type of incident occurring again.
High quality literature used to support the recommendations. Marks 6-7
All recommendations are linked coherently to the predisposing factors
Recommendations are achievable.
Current literature used to support the recommendations. Marks 5-6
Superficial recommendations suggested that are lacking linkage to the predisposing factors.
Recommendations presented are achievable however they may only assist in lowering the risk.
Some literature has been used to support the recommendations but it is not of a high standard.
please also have a table of contents
with:
Background of the Critical Incident
Data
Analysis
Discussion
Recommendations
Rationale
References