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Welcome to Episode Fourteen of our podcast series. This features material from our December 2023 print edition of the Clinical Communiqué. This podcast presents key learnings from the coroner’s inquest into the 2016 thunderstorm asthma event in Melbourne in which ten patients tragically lost their lives. We reflect on the terrifying rapidity with which their conditions changed from mildly short of breath to being in extremis, highlighting that it can be a matter of minutes between life and death in thunderstorm asthma.
Episode Contents
01:13 Editorial by Associate Professor Nicola Cunningham05:37 Case #1: Something in the air by Dr Kristin Boyle20:06 More on the Matter: In the blink of an eye by Associate Professor Nicola Cunningham34:30 Expert Commentary by Associate Professor Matthew Conron and Associate Professor Eve Denton: Thunderstorm asthma: what causes the "perfect storm"? -
Welcome to Episode Thirteen of our podcast series. This features material from our September 2023 print edition of the Clinical Communiqué. This podcast presents the lessons to be learned by examining the failure to hear the concerns of those that should be at the centre of every health care interaction. We present two cases where the patient's families told the coroners that they had not been listened to by the nurses and doctors caring for their loved ones.
Episode Contents
01:25 Editorial by Associate Professor Nicola Cunningham08:14 Case #1: Missing the moments by Dr Angela Sungaila19:12 Case #2: "I told them but no one came" by Associate Professor Nicola Cunningham27:36 Expert Commentary by Ms Belinda MacLeod-Smith: Stolen moments and lost lives38:39 Expert Commentary by Ms Elizabeth Deveny: Engaging patients (and their families) to improve safety -
Fehlende Folgen?
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Welcome to Episode Eighteen of our podcast series. This features material from our November 2023 print edition of the Residential Aged Care Communiqué. This podcast presents the lessons to be learned by examining pre-existing circumstances that contributed to two patients’ falls that caused their deaths. A common underlying factor was timeliness of care.
Episode Contents
00:45 Editorial06:22 Case #1 A fatal fall unwitnessed and unchecked19:41 Case #2 Solving one problem creates another27:58 Reflections of senior nurses -
Welcome to Episode Seventeen of our podcast series. This features material from our August 2023 print edition of the Residential Aged Care Communiqué. This podcast presents the lessons to be learned from the premature deaths of residents due to suboptimal management of diabetes mellitus.
Episode Contents
01:10 Editorial03:51 Case #1 I am fine14:34 Case #2 An old drug and a known complication21:41 Reflections of senior nurses24:04 Commentary: Views of a Diabetes Educator32:31 Commentary: The Contribution of Pharmacists to the Management of Diabetes in the Aged Care Setting -
This podcast episode presents the results of the investigation into the premature death of a resident who had a fall from a runaway wheelchair. The three commentaries draw on clinical and research experts to address how to balance improving mobility with a wheelchair while mitigating potential harm. We also welcome a new narrator Ashleigh Redmond who is a practising registered nurse and actor.
This is Episode Sixteen of our podcast series and features material from our May 2023 print edition of the Residential Aged Care Communiqué.
Episode Contents
01:22 Editorial05:15 Case A fatal downhill slope15:11 Commentary: Falls of wheelchair users: what do we know?19:18 Commentary: Call an OT26:00 Commentary: Looking deeper27:49 Reflections of senior nurses -
In this episode we feature two cases of worsening upper airway swelling leading to fatal airway obstruction following routine extubation of patients after surgery. Despite many advances in airway management, extubation-related incidents have not reduced. The cases highlight the actions leading to the loss of airway protection, a failure to recognise the severity of the situation, and an inability to salvage the situation.
We also welcome a new narrator Ashleigh Redmond who is a practising registered nurse and actor. This is Episode Twelve of our podcast series and features material from our June 2023 print edition of the Clinical Communiqué.
Episode Contents
01:48 Editorial by Associate Professor Nicola Cunningham06:15 Case #1: A fatal toothache by Suzanne Doherty19:54 Case #2: Pulling teeth and tubes - a cautionary tale by Dr Jack D'Arcy36:28 Expert Commentary by Dr Louise Ellard: Extubation: An assessment of risk and strategy -
Escaping, absconding, unexplained absences lead to death. The investigation into a resident’s unexplained absence determined the cause of death as hypothermia secondary to becoming lost in surrounding bushlands. The inquest findings are presented along with expert commentary around how to prevent unexplained absences.
This is Episode Fifteen of our podcast series and features material from our February 2023 print edition of the Residential Aged Care Communiqué. Episode Contents
01:33 Editorial04:05 Case Cold, wet, in the dark, and alone18:42 Commentary: Preventing unexplained absences25:55 What do senior nurses think? -
In partnership with First Nations Peoples from clinical, education, design, and consumer advocacy backgrounds, this critical edition of the Clinical Communique presents two coroners' cases where a lack of cultural safety in the health care system led to preventable and tragic consequences. Special thanks to Mr Olli Wynyard Gonfond who narrated this episode, and Dr Jordana Stanford for her guest apperance.
This is Episode Eleven of our podcast series and features material from our March 2023 print edition of the Clinical Communiqué.
Episode Contents
01:07 Editorial by Associate Professor Nicola Cunningham07:46 Guest Editorial by Ms Belinda Gibb18:33 Case #1: A culture of care by Dr Glenn Harrison28:42 Case #2: Seen but not heard by Dr Jordana Stanford40:11 Expert Commentary by Dr Olli Wynyard Gonfond: Developing cultural safety behaviours and capabilities in health care46:41 Expert Commentary by Ms Jacqui Gibson: Why cultural safety improves patient safety -
Welcome to Episode #11 of the Future Leaders Communiqué podcast. In this episode, we present a thought-provoking summary of the events leading to the tragic death of JL, a 69-year-old woman recovering from an elective neurosurgical operation. We reflect on the challenges faced by junior doctors engaging in locum work and the chain of communication in medical imaging reports.
Episode Contents
01:05 Guest Editorial by Dr Tony Pham04:22 Editorial by Dr Brendan Morrissey07:38 Case: An obstruction in an unfamiliar place by Dr Tony Pham20:07 Expert Commentary #1: Technological solutions: A remedy for human error? By Ms Nicole Mair26:17 Expert Commentary #2: Ready, Set, Go: safe orientation of locum doctors by Dr Brendan Morrissey32:41 Comments from our peers -
The investigations into the deaths of two residents from choking on food are described. Two experts address the challenges of managing the impact of dementia on residents’ ability to eat, as well as, staff managing ethical decision about cardiopulmonary resuscitation.
This is Episode Fourteen of our podcast series and features material from our November 2022 print edition of the Residential Aged Care Communiqué.
Episode Contents
01:53 Editorial04:47 Case #1 Unknown, unknowable and cannot be known17:07 Case #2 We did our best: revisited19:35 Commentary #1: Impact of dementia on eating24:33 Commentary #2: Resuscitation: lessons involving persons with dementia, guardianship and choking32:21 Views from our nursing colleagues -
Two deaths due to head trauma related to use of a mechanical hoist and a lift chair could happen in any aged care home. The lessons for improving practice go beyond the actual cases as illustrated by the accompanying reflective exercises. Commentaries provide insights into recall bias, quality improvement rounds, cognitive testing and parallels with motorised mobility scooters.Episode Contents
01:08 Editorial
06:00 Case #1 Four tales
13:32 Brainstorming about the case: views from our nursing colleagues (Case #1)
16:05 Commentary #1: A literal approach—recall bias
20:06 Commentary #2: Contemplating care—quality improvement rounds
23:51 Case #2 Falling off the chair
30:06 Brainstorming about the case: views from our nursing colleagues (Case #2)
31:48 Commentary #3: See an aside—cognitive testing
35:09 Commentary #4: Drawing parallels—beyond the case
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This episode draws on the September 2022 edition of the Clinical Communiqué and features two cases that describe alarm fatigue and the failure to escalate care. We look at technology and decision-making tools and explore how while they can be used to support clinical processes, there are inherent risks with the loss of critical thinking.Episode Contents01:32 Editorial by Associate Professor Nicola Cunningham05:18 Case #1: An alarming error18:37 Case #2: Deteriorating or not?29:27 Expert Commentary by Dr David Bramley: Perspectives on risk mitigation and alert fatigue
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Welcome to Episode #10 of the Future Leaders Communiqué podcast. In this episode, we reflect on the journey of a complex patient as they transition from an Intensive Care Unit to ward-based care. A breakdown in communication during this transition is the first in a cascade of events that ultimately ends in the patient’s death. In the episode we explore relevant issues in the management of critically unwell patients and the safe transition of care between clinical teams.Episode Contents00:00 Guest Editorial by Dr Tiffany Tie 05:08 Editorial by Dr Brendan Morrissey08:58 Case #1: Lost in translation by Dr Tiffany Tie21:42 Expert Commentary #1: Fluid & electrolyte management by Associate Professor Bruce Lister28:02 Expert Commentary #2: Handover by Associate Professor Bruce Lister30:24 Expert Commentary #3: Escalating care in the deteriorating patient by Dr Resy Van Beek36:17 Comments from our peers
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Welcome to Episode Nine of the Clinical Communiqué podcast, titled ’20 Years of Patient Safety.’ This podcast is split into three parts and is based on the June 2022 edition of the Clinical Communiqué.
This three-part podcast episode showcases a unique collection of expert commentaries about patient safety, featuring some of the most remarkable experts from the fields of medicine, law, ethics, and clinical governance. They all have in common a strong commitment to improving patient safety with extensive careers that have seen many challenges and changes take place in this incredibly complex area of work, and they have very generously shared their insights with us.
Episode Contents
Part 3
01:38 Expert Commentary by Professor Ian Freckelton: Death investigations and COVID-19
10:56 Expert Commentary by Mr Martin Fletcher and Mr Paul Shinkfield: Patient safety and the role of regulators – current and future challenges
18:46 Expert Commentary by Professor Michael Dooley: Twenty-year anniversaries: The Clinical Communiqué and Australia’s National Strategy Quality Use of Medicine
25:20 Expert Commentary by Professor John Banja: Some random observations from a systems thinker on patient safety
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Welcome to Episode Nine of the Clinical Communiqué podcast, titled ’20 Years of Patient Safety.’ This podcast is split into three parts and is based on the June 2022 edition of the Clinical Communiqué.
This three-part podcast episode showcases a unique collection of expert commentaries about patient safety, featuring some of the most remarkable experts from the fields of medicine, law, ethics, and clinical governance. They all have in common a strong commitment to improving patient safety with extensive careers that have seen many challenges and changes take place in this incredibly complex area of work, and they have very generously shared their insights with us.
Episode Contents
Part 2
01:42 Expert Commentary by Emeritus Professor Ron Paterson: Learning from inquiries and experience
10:23 Expert Commentary by Distinguished Laureate Professor Nicholas Talley and Ms Angela Magarry: What does the COVID-19 pandemic teach us about patient safety?
17:19 Expert Commentary by Deputy State Coroner Harriet Grahame: A coroner’s perspective on the pandemic
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Welcome to Episode Nine of the Clinical Communiqué podcast, titled ’20 Years of Patient Safety.’ This podcast is split into three parts and is based on the June 2022 edition of the Clinical Communiqué.
This three-part podcast episode showcases a unique collection of expert commentaries about patient safety, featuring some of the most remarkable experts from the fields of medicine, law, ethics, and clinical governance. They all have in common a strong commitment to improving patient safety with extensive careers that have seen many challenges and changes take place in this incredibly complex area of work, and they have very generously shared their insights with us.
Episode Contents
Part 1
01:43 An anthology of patient safety expert commentaries by Associate Professor Nicola Cunningham
06:50 Editorial by Associate Professor Nicola Cunningham
23:06 Expert Commentary by Dr Annie Moulden: Come so far but still so far to go
28:15 Expert Commentary by Associate Professor Caroline Brand: Ensuring we don’t fall short on safety – reflections of a health service researcher and clinician
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Based on our October 2018 issue of the Future Leaders Communiqué Volume(3) Issue(4) guest edited by Dr Danielle Panaccio. This podcast is hosted by two medical students, Jacqueline Lim (University of Sydney) and Gweneth Ng (Deakin University), it explores how difficulties in recognising and communicating abnormal results from laboratory and imaging investigations leads to significant patient harm.
Read the print edition which explores in detail the coroner’s inquest into missed red flags, resulting in missed opportunities to diagnose and treat a life-threatening condition. The edition also includes reflections of Dr Danielle Panaccio as a junior doctor herself, as well as expert commentaries about how team hierarchy and the gaps in communication between members of a team impact on clinical care.
Time
00:00 Introduction Guest Editors Jacqueline Lim and Gweneth Ng
01:00 Case report of coronial inquest into the death of a 65-year-old man
04:00 Reflections on case with Dr Danielle Panaccio
08:00 Impact of COVID pandemic on clinical work
10:00 Tips for medical students to practice now
12:15 Views of junior doctors on work culture and managing uncertainty
14:05 Wrap-up
Credits
Writer, narrator, producer and director: Jacqueline Lim and Gweneth Ng
Guest interviewee: Dr Danielle Panaccio
Editor: Mia Gvozdic
Producer: Dr Erica Musgrove
Executive Producers: Dr Nicola Cunningham, Prof Joseph Ibrahim, Dr Brendan Morrissey
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Based on our October 2016 issue of the Future Leaders Communiqué Volume(1) Issue(1) guest edited by Dr Nick Lonergan. This podcast hosted by medical student, Dalyia Abu-Ghazaleh (Griffith University), explores how unquestioning adherence to medical protocols could lead to patient harm.
Read the print edition for the detailed case report of the death of a patient that occurred in part, due to the strict adherence of local protocols and provides three expert commentaries about the benefits and potential dangers of medical protocols.
Time
00:00 Introduction Guest Editor Dalyia Abu-Ghazaleh
01:12 Case report
05:00 What is a medical protocol? Vox pop
06:05 Purpose of medical protocols
07:15 Origins of protocols: aviation industry
08:20 Protocols are not an absolute
09:30 Better use and questioning of protocols
10:26 Closing
Credits
Writer, narrator, producer, and director: Dalyia Abu-Ghazaleh
Editor: Mia Gvozdic
Producer: Dr Erica Musgrove
Executive Producers: Dr Nicola Cunningham, Prof Joseph Ibrahim, Dr Brendan Morrissey
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Death of a resident from positional asphyxia. Highlights need for better internal emergency incident responses and deploying staff.
Editorial Content
01:31 Editorial: Professor Joseph Ibrahim
05:03 Case #1 Get me out by Dar Ray Ooi
16:40 Commentary #1: Advance Care Planning by Barbara Hayes
26:20 Commentary #2: Improving outcomes for residents by Anita Westera
31:05 Special article examining Selected Recommendations from the Royal Commission
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Welcome to Episode Nine of our Podcast Series. A preventable death of a six-year-old child is a tragedy. We highlight some of the lessons to be learned from this case, to inform and evolve your clinical practice in timely recognition, and management of sepsis in children. Two expert commentaries address post-splenectomy infections and an approach to the asplenic patient.
Editorial Content
01:15 Editorial by Brendan Morrissey
05:09 Case #1 Asplenia—think sepsis by Dr David Brough
18:16 Expert Commentary #1: Overwhelming Post-Splenectomy Infection – Tips and Traps for Junior Doctors by Associate Professor Merrole Cole-Sinclair
27:39 Expert Commentary: An Approach to the Asplenic Patient by Professor Clare Nourse
31:54 Comments from our peers
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