Posted: September 11th, 2023

“From Death We Learn – Opioid toxicity”:

Assessment Brief
School of Nursing and Midwifery

NUR3605 – Leadership, Governance and Culture
Ass. Item # Assessment Type
As stated in CAPS
Click on textbox below to select the CAPS Assessment Type
Assessment Description
As stated in CAPS Weighting Word count
Undergraduate
10% = 300-350 words
Postgraduate:
10% = 500 words
1 Assignment Report 50% 1750 words

Due date and submission information Submit via CANVAS in Turnitin by 4pm, September 4th 2023. Please ensure that you have read and understood the ‘before you submit an assignment’ information attached to this assignment brief.

Why am I doing this assessment?
This assignment will help you to understand and demonstrate the following unit learning outcomes (ULO):
1. Critique best practice principles for governance in the clinical environment.
2. Explain the roles of nurses and other health professionals in implementing quality improvement methodologies.
3. Examine how the National Safety and Quality Health Service standards govern clinical practice.

By completing these ULOs, you are demonstrating that you are working towards the following course learning outcomes (CLOs) and therefore, the related professional standards:
• CLO2: Critically analyse, interpret, and conceptualise complex nursing practice.
• CLO4: Access, evaluate and synthesise relevant information from multiple sources using digital technologies to inform nursing practice.
• CLO5: Independently communicate nursing knowledge, concepts and values clearly and coherently.
The following course learning outcome/s will also be consolidated in this unit:
• CLO6: Demonstrate a global outlook with respect for cultural diversity, including Indigenous cultural competence.
• CLO8: Demonstrate autonomy, accountability and judgement for own learning and professional nursing practice in accordance with the Nursing and Midwifery Board of Australia standards for practice.
Employability skills addressed
Select all that apply
EMPLOYABILITY SKILLS
0 Reflective practice
1 Decision making
1 Critical thinking
1 Problem solving
1 Communication
0 Digital literacy
0 Conflict resolution
0 Time management
0 Teamwork
0 Cultural competency
1 Leadership
1 Creativity and Innovation
PERSONAL ATTRIBUTES
0 Self-awareness
0 Self-efficacy
1 Professional identity
0 Resilience
0 Interpersonal skills
1 Interprofessional coordination
0 Emotional intelligence
0 Cross-cultural awareness

CAREER MANAGEMENT SKILLS
0 Self-awareness
0 Career decision making
1 Opportunity awareness
0 Transition learning
0 Career planning
1 Specialist skills (course specific)

Assessment Task Instructions
The assessment instructions have been designed to enable you to understand what is required to succeed in this assignment.
The aim of this Assignment is to show your understanding of the process by which sentinel events are reviewed and learning occurs – making way for improvements in the future. The process of completing this assignment will consolidate your understanding of quality improvement methodology.
• Step 1: Read the attached From Death We Learn – Opioid toxicity. Note that this is an incomplete replication of the original as we want you to come up with your own ideas and actions.
• Step 2: Use a systematic approach to review the case and identify possible causes of the event. Determine two main themes or situational factors that you wish to address in the following steps. In the appendix show the systematic approach you took to review the case and the findings you made.
o In your discussion of this event, you are NOT required to make professional or clinical care recommendations in regard to the actions of the nurses/health care workers involved.
• Step 3: Based on your findings in step two, review relevant literature to determine what should have occurred in this scenario, noting if there were gaps in practice or deviations from best practice guidelines in relation to the two areas you wish to focus improvements on.
• Step 4: Discuss the case in relation to what you have found in step 3
• Step 5: Using a quality methodological approach recommend two actions, supported by literature that could be implemented for a change in practice to circumvent such events recuring.

Format and Structure
This is a formal report, and you must follow the guidelines provided below and those in the tutorials and Canvas site:

• Title Page
• Executive summary/abstract (max 200 words- non-structured, must be a summary of the entire report, not a replication of the introduction)
• Table of contents
• Introduction (Approx 150 words)
• Background – relevant review of literature for best practice (Approx 300 words)
• Discussion – relate the case to the findings in the literature, policies and best practice documents (Approx 600 words)
• Recommendations for two changes in practice (Approx 300 words)
• Conclusions (Approx 200 words)
• References (APA7th)

For general formatting, please follow the SNM assessment guide
What you should include
Please refer to the report writing ppt in Canvas

Connecting your learning
Assessment tasks in this course are designed to give you opportunities to integrate what you learn into or from other units.
Marking rubric
The marking rubric has been attached to the assessment in Canvas.

Feedback and moderation
Your results and feedback will be released in 15 working days from submission via Turnitin.
All unit assessments are subject to a robust moderation process. Note that results are not final until they are officially released at the end of semester following ratification at the progression panel and are therefore subject to change.
Additional Resources

• Library Referencing Guide
• Academic Integrity

“From Death We Learn – Opioid toxicity”:
Introduction
This report examines a sentinel event case study involving opioid toxicity that resulted in patient death. A systematic review of the case identifies two key themes – gaps in opioid administration guidelines and lack of interprofessional communication – that contributed to this tragic outcome. Recommendations are proposed to address these issues through quality improvement initiatives.
Background
Proper opioid administration and monitoring are essential to prevent adverse events like overdose (National Health Service, 2018). Guidelines outline safe dosing limits, required monitoring, and steps for identifying and treating overdose (Australian and New Zealand College of Anaesthetists, 2016). However, gaps and lack of standardized protocols can lead to errors (The Joint Commission, 2016).
Effective interprofessional communication is also vital for patient safety. The World Health Organization (2020) emphasizes sharing complete patient information, especially during care transitions. However, siloed documentation and unaddressed assumptions can impede coordination (Kohn et al., 2000).
Discussion
In this case, gaps in the opioid administration guidelines may have contributed to exceeding the safe dosing limits. While the patient’s condition merited around-the-clock monitoring, protocols did not clearly define responsibilities during shift changes. Furthermore, lack of communication between nurses potentially led to missing signs of impending overdose.
Recommendations
To address these issues, I recommend:
Developing a standardized electronic opioid administration protocol outlining clear dosing limits, required monitoring, and responsibilities during shift changes. This could help minimize human errors from gaps or inconsistencies in existing guidelines.
Implementing bedside handoff reporting to facilitate real-time information exchange between nurses. Including all caregivers would help surface any assumptions and ensure no details are overlooked (World Health Organization, 2020).
Conclusion
Sentinel event reviews provide valuable lessons to enhance safety. By addressing the systematic and human factors identified, these quality improvement recommendations aim to help circumvent similar tragic outcomes in the future.
References

Australian and New Zealand College of Anaesthetists. (2016). PS09 guideline on acute pain management. https://www.anzca.edu.au/getattachment/resources/professional-documents/ps09-2016-guidelines-on-acute-pain-management.pdf
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (2000). To err is human: Building a safer health system. National Academies Press.
National Health Service. (2018). Safe and appropriate use of high-risk medications. https://www.england.nhs.uk/publication/safe-and-appropriate-use-of-high-risk-medications/

The Joint Commission. (2016). Sentinel event alert: Safe use of opioids in hospitals. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-56-safe-use-of-opioids-in-hospitals/
World Health Organization. (2020). Communication during patient hand-overs. https://www.who.int/publications/i/item/communication-during-patient-hand-overs

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