Case Study (Safety and Quality)

Case Study (Safety and Quality)

 

 

Assessments must be submitted via turnitin, using the format outlined on the following pages. The assessment is an individual piece of work and students sharing answers, working in a group or colluding will be deemed academic misconduct.

Note this is not a clinical case study and the questions should be answered in essay format using appropriate headings.

Case Study Question

An ambulance was dispatched to attend a 65 year-old patient with heart failure in the community. While treating this patient, a paramedic mistakenly pushes 1ml of intravenous 1:1,000 adrenaline instead of the intended lookalike vial of 1ml of 1:10,000 adrenaline.

The patient immediately develops a supraventricular tachycardia, becomes hypertensive, and deteriorates into ventricular fibrillation. Resuscitative efforts are unsuccessful; the patient is pronounced dead on arrival at the ED.

Further information:

The incident occurred at 0200 hours, 8 hours into the paramedics shift. They had already completed 7 previous emergency jobs, and had not eaten or taken a break. The incident occurred at a homeless shelter, where the staff refused to turn the main lights on for the paramedics. It was raining and the paramedics had to park and walk 250m to access the shelter.

There was limited clinical information available on the patient and they were unable to accurately describe their past medical history or allergies.

The paramedic treating the patient had over 10 years’ experience, and was working with a newly graduated paramedic. The treating officer did not conduct the 5 rights of medication administration. The Service’s guidelines on use of medications was available on their electronic report form, but neither paramedic referred to them.

The ambulance service had recently introduced new packaging with new labelling for adrenaline, and an online learning package. However the treating paramedic hadn’t completed the package at the time of this incident; although the new grad had completed the package.

Using the information presented in lectures and readings, specifically in relation to this case:

  • Using an accident causation model (such as Reason’s), identify and outline, from a systems perspective, the errors in this clinical scenario.
  • Analyse the human and system factors which influenced the errors.
  • Describe the process and systems actions you would recommend to improve patient safety 
and prevent similar errors.

 

 

 

The marking rubric for this assessment is given below.

  Weighting Below Pass < 49% Pass 50 – 59% Credit 60 – 69% Distinction 70 – 79% High Distinction 80%+
Demonstrated understanding of underpinning theory 20% Your answer demonstrates very limited understanding of the underpinning theory. Your answer demonstrates some understanding of the underpinning theory. Your answer demonstrates clear understanding of the underpinning theory, with consideration of some different perspectives. Your answer demonstrates a well developed understanding of the underpinning theory, with consideration of a range of different perspectives. Your answer articulates a strong understanding of the underpinning theory, with consideration of an extensive range of perspectives.
Critical Thinking and Application 30% Your answer demonstrates inadequate understanding of the contemporary literature and application to paramedic practice. Limited to no logical rationale has been provided. Your answer demonstrates some understanding of the aspects of the contemporary literature and application to paramedic practice to support your ideas. Your answer demonstrates an appropriate level of understanding of the aspects of the contemporary literature and application to paramedic practice. Clear rationale has been provided. Your answer effectively demonstrates an excellent level of understanding of all aspects of the contemporary literature and application to paramedic practice. Clear rationale has been provided. Your answer articulates a comprehensive understanding of all aspects of the contemporary literature and application to paramedic practice. Convincing rationale has been provided.
Articulation and Argument 30% Your answer did not demonstate a coherent position on the topic / question, providing little evidence of integration between theory and practice.

Few or no credible and/or relevant sources have been used to support the development of your ideas.

Your answer demostrated a limited position on the topic / question, with a basic understanding of theory and application.

Demonstrates use of academic sources to support the development of your ideas – but primarily secondary used.

Try to ensure that your sources are relevant to the topic and/or from credible primary sources.

Your answer demonstrated a sound position on the topic / question, with relevant examples and reasons linking theory and application.

Demonstrates use of a mix of academic sources, but weighted more towards secondary sources and not contemporary primary sources

Try to ensure your argument consistently uses contemporary primary academic sources.

Your answer demonstrated a robust position on the topic / question, with relevant well- chosen examples and reasons linking theory and application. Clear rationale has been provided.

Consistent use of highly appropriate primary academic sources which are credible and relevant to the topic no more than 7 years old.

Your answer demonstrated an insightful position on the topic / question, with relevant compelling, persuasive examples and reasons linking theory and application. Convincing rationale has been provided.

Articulates strong evidence from highly credible primary academic sources no more than 7 years old.

Spelling, grammar, language(ELP Measure) 5% Your writing contains significant spelling, grammar and language errors, which impact the reader’s ability to interpret meaning from your writing.

You may wish to contact an ECU Learning Advisor for assistance with your writing.

Some grammar, spelling and language errors were present in your writing, which impact the quality of your expression.

It may be beneficial for you to proof read your writing carefully before submitting.

There is good clarity of expression in your writing; your spelling, grammar and language are of a high standard. Consistent use of the third person. Grammar, spelling and language are of a high standard; you have used complex sentences and language and the third person. Grammar, spelling and language are of a very high standard; you have used highly sophisticated language and expressed yourself concisely.
Referencing 10% In-text and end-text referencing is not attempted or is very poorly handled with many errors. Referencing does not comply with APA guidelines. In-text and end-text referencing is attempted but contains several errors. In-text and end-text referencing is attempted but contains minor errors. In-text and end-text referencing is well handled but contains a few very minor errors. In-text and end-text referencing is expertly handled and error free.
Presentation and Structure 5% Significant deviation from word limit and/or does not follow approved assignment structure and presentation Submission adheres to the word limit +/- 10%. Submission includes completed ECU cover page with small errors in assignment guidelines. Within + 10% of word limit
Fully follows approved assignment structure and presentation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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