Clinical Governance
How do you access policies, procedures and guidelines?
The Policy Distribution System (PDS) can be accessed on the intranet home page under the Policies and Procedures tab
How do we involve patients and their families to plan, communicate, set goals and make decisions about care?
- family meetings
- MDT
- safety huddles
- bedside clinical handover
What is the most effective way to prevent cross infection?
Hand hygiene
How and where do you report a medication error?
- inform TL/NUM
- inform team
- open disclosure with patient
- IIMS+
What are the processes in place to track and complete mandatory training in your workplace?
We can access our mandatory training records through My Health Learning
The CNE keeps record of what mandatory training is complete and what is due
We can attend mandatory training face to face sessions facilitated by CNE
Attendance of paid mandatory training days like VPM, Respecting the Difference
When is it appropriate to wear non-sterile gloves?
When coming into contact with body fluids, non-intact skin or mucous membranes, and handling cytotoxic medications, waste, linen or contaminated surfaces
What safety checks are required before administering a medication?
6 rights -
right medication; right dose; right person; right time; right route; right documentation
How would you manage a situation where a patient or their family wishes to make a complaint?
Listen to the person
De-escalate emotional state if needed
Repeat back to ensure you understand the person's account
Problem solve to meet immediate patient needs/rectify what you can
Refer person to complaints form if wanting to make formal complaint
Escalate to NUM/AHNM if beyond your ability to solve
Document clearly and objectively
If a patient doesn't have capacity, who else can make medical decisions?
- an appointed guardian with the function of consenting to medical and dental treatment
- a spouse or defacto
- the carer or person who provides or arranges domestic services and care
- a close friend or relative, provided they are not receiving renumeration
What are the key principles for inserting any invasive device in a patient?
- indication for insertion
- informed consent
- aseptic technique
- documented plan for care and removal
How do you know if a patient has an existing medicine allergy or ADR?
- check allergies and ADRs on EMR
- red ID band
- ask the patient
What processes are in place for auditing and reporting in your workplace?
QARS - CNE and nursing staff complete each month. These are reported at staff meetings and in QARS report to NUM/DDON/DON
WHS audit - nursing staff attend each month
Risk assessment audits - CNE attends and reports at ward meeting
What are the requirements of obtaining valid consent?
- the patient has capacity
- consent must be freely given
- consent must be specific to the procedure or treatment
- consent must be informed
What is Antimicrobial Stewardship?
The term used to describe the activities, strategies, and coordinated interventions designed to optimise antimicrobial usage, including -
- using antimicrobials only when needed
- selecting antimicrobials wisely
- using safe and effective doses