Welcome to the April edition of the Future Leaders Communiqué. As return readers will know, each edition of the Future Leaders Communiqué presents cases of preventable health care-related deaths and explores the systemic issues and errors identified in the ensuing coronial investigations. All junior medical officers (JMOs) working in a hospital setting will relate to these issues – I’m sure we can all recount a ‘near-miss’ situation that has stuck with us and informed our day-to-day work.
Welcome to the first edition of the Clinical Communiqué for 2019. In this edition, we discuss fixation error, the phenomenon whereby a person or group falls into a pattern of thinking that there is only one possible explanation. This can take on several forms, including task fixation on a procedure, or diagnostic fixation to the exclusion of other possibilities, as unfortunately demonstrated in the two cases presented.
Residential Aged Care Communiqué Download PDF: RAC Communiqué February 2019 In this edition Editorial Case Précis: Too Much Too Soon Commentary #1: The coroner’s recommendations and requirement of organisations to respond Summary of organisational responses to the coroner’s findings and recommendations Management of BPSD: A refresher Resources In the news recently The ‘Dignity of Risk’ Film […]
Welcome to the final issue for 2018. We present the findings of the Coroner’s Inquest into a resident death at an aged care facility in Oakden, South Australia, that occurred in 2008. The finding was delivered in September this year, more than 10 years after the death of the resident.