Clinical Governance report

Clinical Governance report

Severity assessment code SAC matrix,Root causes analysis RCA, NMBA competencies will be attached with this paper.
The task in this assignment is to:
Write a ‘Formal Investigative Report’ about a critical incident that has occurred.

Please use the below as a guide of what to include in this report;

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Introduction/Background to the Incident: A short introduction including what the report is about followed by a brief background to the critical incident. Using the Severity Assessment Code (SAC) Matrix allocate a rating and explain why you gave this score.

Factors/ Flow chart: 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 ‘factors’ 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.

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 NMBA 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.

Rationale
A Registered Nurse is expected to be able to reflect on and analyse their clinical practice and to be aware 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 assurance processes and to gain an understanding of the importance of their role as a Registered Nurse in regard to patient safety.

This assignment addresses the following learning outcomes:

be able to describe and explain the nurses’ scope of practice, including legal obligations and constraints (aligns with Nursing and Midwifery Board of Australia National Competency Standards for the Registered Nurse: 1.1, 1.2, 2.1, 2.2, 2.5, 8.1, 8.2).
be able to critically analyse incidents involving patient safety and make appropriate recommendations(NMBA 1.2, 2.1, 2.2, 2.5, 3.2, 6.4, 9.1, 9.2, 10.2, 10.3).
be able to use the principles of clinical governance and quality improvement to undertake a root cause analysis related to nursing practice (NMBA 1.3, 2.2, 2.4, 3.3, 3.4, 3.5, 4.1, 7.4, 7.8, 8.1, 10.4).
be able to demonstrate leadership and management strategies by providing recommendations for changes in health care practice to address quality issues (NMBA 1.3, 2.2, 2.4, 2.5, 3.5, 7.4, 7.5, 7.6, 9.2, 10.2, 10.3, 10.4).
Marking Criteria
1.Description of health related incident- SAC rating:
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.
SAC rating with explanation provided.
2.Incident factors / Flow chart:
A clear, concise and detailed description of all the factors leading to the critical incident is provided

Provides a flow chart that is visually appealing which clearly demonstrates the complex details of the incident in a logically connected format which is easy to understand.
3.Analysis/ Patient Safety Model:
Proveds an analytcial interpretation of all the factors that were the root causes that lead to the incident.
Inter-related factors are identified.
Analysis of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which clearly demonstrates the findings and displays logical
thought.
4.Discussion:
Discussion provided is clear concise and explores the complexity of the root causes of the incident and explains how this relates to current
evidence based
best practice
guidelines and at least 2
relevant NMBA
competencies.
5 or more credible sources are provided that support the discussion.
5.Recommendations:
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
6.Presentation, referencing, grammar and spelling
No marks awarded, however a penalty of up to 5 marks can be applied for poor presentation:
Work is legible and well presented with consistent formatting throughout
Pages in the report are formatted as required
Name and student number on each page
Cover page is attached
Paragraphs, flowcharts or diagrams flow which easily demonstrate the intended information and enhance the report.
Grammar, spelling and punctuation are correct.
The report is well structured

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