Reff A description of some references

Reff A description of some references


Brown, P. M., Mcarthur, C., Newby, L., Lay-Yee, R., Davis, P., & Briant, R. H. (2002). Cost of Medical Injury in New Zealand: A retrospective cohort study. Journal of Health Services Research and Policy, 7(Suppl.1), S29-S34. doi:10.1258/135581902320176449

Cowan, P. J. (2002). The role of clinical audit in risk reduction. British Journal of Clinical Governance, 7(3), 220-223. doi:10.1108/14664100210438388

Davis, P. D., Lay-Yee, R., Briant, R. H., Schug, S., Scott, A., Johnson, S., & Bingley, W. (2001). Adverse events in New Zealand public hospitals: Principal findings from a national survey. Wellington, New Zealand: Ministry of Health.

Eggins, S., & Slade, D. (2015). Communication in Clinical Handover: Improving the Safety and Quality of the Patient Experience. J Public Health Res, 4(3), 666. doi:10.4081/jphr.2015.666

Ewen, B. M., & Bucher, G. (2013). Root Cause Analysis: Responding to a sentinel event. Home Healthcare Nurse, 31(8), 435-443. doi:DOI:10.1097/NHH.0b013e3182a1dc32

Kilic, S. P., Ovayolu, N., Ovayolu, O., & Ozturk, M. H. (2017). The Approaches and Attitudes of Nurses on Clinical Handover. International Journal of Caring Sciences, 10(1), 136-145.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academies Press.

Levy, B., & Rockall, T. (2009). The role of clinical audit in clinical governance Surgery, 27(9), 367-370. doi:

Manser, T. (2013). Fragmentation of patient safety research: a critica; reflection of current human factors approaches to patient handover. Journal of Public Health Research, 2(33), 194-197.

National Ambulance Sector Clinical Working Group. (2016). Clinical Procedures and Guidelines – Comprehensive Edition. Retrieved from Wellington, New Zealand.:

Reason, J. (2000). Human Error: Models and Management British Medical Journal, 320(7237), 768-770.

Reason, J. (2004). Beyond the organisational accident: the need for “error wisdom” on the frontline. Qual Saf Health Care, 13 Suppl 2, ii28-33. doi:10.1136/qhc.13.suppl_2.ii28

Sills, E. (2017). HALT: Take a break— patient care depends on it. British Journal of Cardiac Nursing, 12(5), 225-225. doi:10.12968/bjca.2017.12.5.225

Stow, J., Morphet, J., Griffiths, D., Huggins, C., & Morgan, P. (2017). Lessons learned developing and piloting interprofessional handover simulations for paramedic, nursing, and physiotherapy students. J Interprof Care, 31(1), 132-135. doi:10.1080/13561820.2016.1251404

Tranchard, S. (2018). The New ISO 31000 keeps risk management simple. Retrieved from

Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and Efficiency of Root Cause Analysis in Medicine Journal of the American Medical Association, 299(6), 685-687.

Boult, M. & Maddern, G.J. (2007). Clinical audits: Why and for whom. ANZ Journal of Surgery, 77, 572-578.

Braine, M.E. (2006). Clinical governance: Applying theory to practise. Nursing Standard, 20 (20), 56-65.

Cashmore, J. (2010). Seizures in the prehospital setting. Journal Of Paramedic Practice2(7), 304-309. doi: 10.12968/jpar.2010.2.7.49071

Crimes Act 1961.

Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996.

Health and Disability Commissioners Act 1994.

Pellock, J., & Seinfeld, S. (2014). Is there a need for further trials for the treatment of prolonged seizures?. Epileptic Disorders16(NS1), 103-107. doi: 10.1684/epd.2014.0693

Reason, J. (2000). Human error: models and management. BMJ: British Medical Journal , 320(7237), 768.

Sherwin, J. (2011). Contemporary Topics in Health Care: Root Cause Analysis. PT in Motion3(4), 26-31.

St John. (2016). Clinical Procedures and Guidelines, 2016-2018

World Health Orgaisation. (2011). Patient Safety Curriculum Guide: Multi-professional Edition Retrieved from;jsessionid=8596311FEA34435E47F0020BCF67AD0B?sequence=1

BS ISO 31000:2018. (2018). Retrieved 14 October 2019, from

Legislation and Standards

ISO 31000:2018 (2018).

The Health and Disability Commissioner Act (1994).

The Human Rights Act (1993).

The Privacy Act (1993).


You should speak here about your assignment and maybe factors which cause poor communications or the human factors associated with what you have chosen to be your topic Maybe the different factors of communications that has been a human factor which has caused the error.

Here you should also discuss the risk management and the areas of clinical governance and how they are connected to Risk management. What investigation techniques are used such as RCA and how What clinical audit is in relationship to Clinical governance.


Here you must describe the methods you used to obtain this information eg

Electronicsearches of Medline, CINAHL and SCOPUS were performed for studies related to clinical risk. The computer databases provided access to journals, serial publications and books published since 2000. The key words used were: risk management, Nursing and Paramedic practice ethical framework and seizure treatment. Course material presented in AUT paper PARA704 Clinical Risk Management relevant to the report topic has been incorporated. Exclusion of resources occurred when they were either not in English or the full text was unavailable.


You should explain what Reason (2000) discusses and about Human factors and how this retlates to your subject.

You should look at the study by Brown (2002) about amount of money spent on health care incidents in NZ.

Have a look at Davis (2001) about adverse events in hand over.

Discuss the human factor science Human factors is the science of the relationship between a human and the system, technologies or environment.

(Kohn, Corrigan, & Donaldson, 2000)

Look at studies by Reason (2000)

And describe the two approaches to managing errors the Systems and the Person centred approach and describe these. Look at Kohn (2000) about blame culture.

Describe the HALT and IMSAFE Method for human factors. Sills (2017)

Discuss the Swiss cheese model and include a diagram of how this works include Active Failures and Latent Conditions. Reason (2004)

Discuss Slips and Lapses mistakes or procedurals violations

Figure 1. Accident causation model. Reprinted from Garfield, S. & Franklin, B. D. (2016) Human Error: Understanding models of error and how they apply in clinical practice. The Pharmaceutical Journal, 296(7890), 361–364. Retrieved from


Discuss the three approaches to risk management (ISO 31000)

Continuous improvement

Reference NHS Clinical governance framework and definition.

“Clinical governance can be defined as a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” › about › trust › healthcare-governance › clinic…

Clinical Governance is accountable for safety of patients and maintaining quality care. This is maintained through multiple audit systems

Describe clinical audit and how it connects to Clinical governance.

Figure 2. The framework of clinical governance. Reprinted from Gottwald, M., & Lansdown, G. (2014). Clinical Governance: Improving the quality of healthcare for patients and service users. Maidenhead: McGraw-Hill Education. Retrieved from

(Braine, 2006).

The ISO 31000:2009 was a document formed by the International Standards Organisation (ISO), described as a family of risk management standards, to provide best practice advice and structure on any process involving risk management.

The ISO states that the second edition, ISO 31000:2018, is more concise, clear and shorter than its predecessor, giving organisations better tools to face the increased risk and uncertainty in todays’ climate (Tranchard, 2018). Although adopted by the UK (British Standards Institution, 2018), Australia and many other countries,

New Zealand has yet to move to the 2018 edition. The document directs organisations on how to treat risks, and encourages regular monitoring and review, to ensure improved outcomes. Full commitment is essential from all involved personnel in implementation this system into the workplace.

Discuss RCA methodology (Ewen & Bucher, 2013). (Wu, Lipshutz, & Pronovost, 2008).


Figure 1. Principles, Framework and Process. ISO310000:2018. Pg 5


Discuss nursing and or Dr registrations and how this protects patients

Discuss The Health and Disability Commissioner Act (1994) explains the rights of the patient when seeking healthcare, as set out in the Code of Rights.

Discuss the rights which are breeched in your topic.

Discuss the The Human Rights Act (1993) protects all citizens against discrimination including age, gender, political views or disability.

Discuss The Privacy Act (1993) and how sets out the 12 Information Privacy Principles, which outlines provisions for the management of personal information. Principle 11 covers Disclosure, which is especially relevant for Nurses and paramedics and their patients’ health information.


In Conclusion, This should briefly discuss your assignment and should not include anything new. A sentence from each heading is enough.


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