course material

1. Formal Investigative Report – Death resulting from haemorrhage due to
incised wound
Topic: Formal Investigative Report – Death resulting from haemorrhage due to incised
woundTaskClinical Governance is the term used to describe a systematic approach to
maintaining and improvingthe 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 responsibilityfor making sure this occurs.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 the death resulting from haemorrhage due to incised wound as
reported by the South Australian Coroner.Please use the below as a guide of what you need
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 theylead 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 toidentify 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

2. develop a deeper understanding of thewhy the incident occurred, what should have
happened and how it could be prevented in the future.The National Practice Standards for
the Mental Health Workforce 2013 should be discussed in relation to professional best
practice with two (2) relevant practice standards 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 therecommendations 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.RationaleA health professional is expected to be able to reflect on and analyse
their clinical practice and to beaware of the systems in which they function. It is important
to be aware of and involved in quality improvement processes. This assessment task will
allow the student to explore these quality assuranceprocesses and to gain an understanding
of the importance of their role as a health professional in regards to patient
safetyPresentationThis assignment must be presented as a ‘ Formal Investigative Report’
and should consist of the following sections:Title PageTable of
contentsIntroduction/Background to the Incident.Data: with a flowchart diagramAnalysis:
with a patient safety model diagramDiscussionRecommendations