Welcome to the winter 2017 edition of the Clinical Communiqué. Since our last edition, we have seen interest in our publication continue to grow, and we have been heartened by the feedback we continue to receive from our readers about the lessons learned.
Welcome to the final issue for 2016. In this issue we look at three cases where medication errors contributed to the cause of death. There is extensive literature available on the types of medications errors, their prevalence, and the hard work that has been done so far to reduce this substantial cause of adverse events in healthcare settings. The Australian Commission on Safety and Quality in Healthcare identified the importance of improving the safety and quality of medication usage in Australia, and listed it as a National Safety and Quality Health Service Standard (NSQHS Standard 4).
This issue describes two cases where systemic errors resulted in delays of recognition and treatment of a clinical situation. A schedule for 2010 Open Days and an update on the electronic medical deposition are also provided. Also, the introduction of the new Coroners Act 2008(VIC) on the 1st November 2009 with a focus on prevention, and the obligation for the Coroners Court to publish their findings, comments and recommendations following an inquest.
This Clinical Communiqué case study demonstrates the importance of safe and adequate post-operative monitoring of patients. Preventing respiratory depression due to the use of pain medications can be challenging, even in young adult patients with no premorbid conditions.