The Communiqués Podcasts: Recent Episodes
The Communiques
Welcome to The Communiqués Podcasts. The objectives of The Communiqués are to develop, produce and distribute electronic educational publications that encourage clinical practice changes for the benefit of patients, residents, health and aged care services and the whole community. Over half of our subscribers attribute a change in their clinical practice due to The Communiqués. The print versions and these podcasts present cases of premature and preventable deaths that occur in health and aged care settings. We explore 1) What happened? 2) Why did it happen? 3) What action can we take to prevent it from happening again? The cases are the accounts from completed medico-legal death investigations of the Coroners Courts, and our team of senior medical and nursing practitioners present the coronial information in a manner and format that is familiar to clinicians. Our three publications are the Clinical Communiqué focussing on acute care, the Future Leaders Communiqué designed for recent health graduates, and the Residential Aged Care Communiqué which examines preventable deaths in aged care or nursing homes. The print versions and links to our podcasts are available at our website at https://www.thecommuniques.com/, which also features the resources recommended for each edition.
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 Cunningham
- 08:14 Case #1: Missing the moments by Dr Angela Sungaila
- 19:12 Case #2: "I told them but no one came" by Associate Professor Nicola Cunningham
- 27:36 Expert Commentary by Ms Belinda MacLeod-Smith: Stolen moments and lost lives
- 38:39 Expert Commentary by Ms Elizabeth Deveny: Engaging patients (and their families) to improve safety
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 Editorial
- 06:22 Case #1 A fatal fall unwitnessed and unchecked
- 19:41 Case #2 Solving one problem creates another
- 27:58 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 Editorial
- 03:51 Case #1 I am fine
- 14:34 Case #2 An old drug and a known complication
- 21:41 Reflections of senior nurses
- 24:04 Commentary: Views of a Diabetes Educator
- 32:31 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 Editorial
- 05:15 Case A fatal downhill slope
- 15:11 Commentary: Falls of wheelchair users: what do we know?
- 19:18 Commentary: Call an OT
- 26:00 Commentary: Looking deeper
- 27:49 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 Cunningham
- 06:15 Case #1: A fatal toothache by Suzanne Doherty
- 19:54 Case #2: Pulling teeth and tubes - a cautionary tale by Dr Jack D'Arcy
- 36:28 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 Editorial
- 04:05 Case Cold, wet, in the dark, and alone
- 18:42 Commentary: Preventing unexplained absences
- 25:55 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 Cunningham
- 07:46 Guest Editorial by Ms Belinda Gibb
- 18:33 Case #1: A culture of care by Dr Glenn Harrison
- 28:42 Case #2: Seen but not heard by Dr Jordana Stanford
- 40:11 Expert Commentary by Dr Olli Wynyard Gonfond: Developing cultural safety behaviours and capabilities in health care
- 46:41 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 Pham
- 04:22 Editorial by Dr Brendan Morrissey
- 07:38 Case: An obstruction in an unfamiliar place by Dr Tony Pham
- 20:07 Expert Commentary #1: Technological solutions: A remedy for human error? By Ms Nicole Mair
- 26:17 Expert Commentary #2: Ready, Set, Go: safe orientation of locum doctors by Dr Brendan Morrissey
- 32:41 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 Editorial
- 04:47 Case #1 Unknown, unknowable and cannot be known
- 17:07 Case #2 We did our best: revisited
- 19:35 Commentary #1: Impact of dementia on eating
- 24:33 Commentary #2: Resuscitation: lessons involving persons with dementia, guardianship and choking
- 32:21 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
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 Contents 01:32 Editorial by Associate Professor Nicola Cunningham * 05:18 Case #1: An alarming error * 18:37 Case #2: Deteriorating or not? * 29:27 Expert Commentary by Dr David Bramley:* Perspectives on risk mitigation and alert fatigue
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 Contents 00:00 Guest Editorial by Dr Tiffany Tie * 05:08 Editorial by Dr Brendan Morrissey * 08:58 Case #1: Lost in translation by Dr Tiffany Tie * 21:42 Expert Commentary #1: Fluid & electrolyte management by Associate Professor Bruce Lister * 28:02 Expert Commentary #2: Handover by Associate Professor Bruce Lister * 30:24 Expert Commentary #3: Escalating care in the deteriorating patient by Dr Resy Van Beek* * 36:17 Comments from our peers
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
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
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
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
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
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
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
Welcome to Episode Eight of the Clinical Communiqué podcast, titled ‘Fall injuries in older adults.’
This podcast is based on the March 2022 edition of the Clinical Communiqué.
In this podcast we look at some of the specific challenges clinicians face in assessing older patients following a fall where the extent of injury was not fully appreciated until it was too late.
The expert commentary by Dr Glenn Arendts provides practical measures to deal with the low signal/high noise scenario of a fall in the older patient, with a key focus on the importance of retiring a commonly used phrase to reduce the risk of anchoring bias in the clinical care of these patients.
Episode Contents
- 02:20 Editorial by Dr Nicola Cunningham
- 06:54 Case # 1: Don’t fall for it: Fall injuries in the older person are serious
- 15:09 Case # 2: Tunnel vision strikes again
- 21:04 More on the Matter:From up high or down low
- 25:06 Expert Commentary by Dr Glenn Arendts: The trips and traps of falls
The first issue of Residential Aged Care Communiqué for 2022 focuses on falls and falls management. Every year, over half of all residents will have a fall and some have grave consequences as highlighted by the two cases. Commentaries by two of Australia’s leading international experts explain the practical interventions available to prevent falls. Editorial Content
- 01:09 Editorial: Professor Joseph Ibrahim
- 03:34 Case #1 Is this preventable?
- 08:03 Case #2 The last fall
- 11:52 Commentary #1: Tips to reduce risk of falls by Professor Jacqueline Close
- 18:52 Commentary #2: Fall prevention: an ongoing need by Professor Keith Hill
Welcome to Episode Nine of our Podcast Series. This is the second part of a two-part collection featuring material from our January 2022 print edition of the Future Leaders Communiqué.
In this second part we provide a collection of commentaries that include frank and honest views from a junior medical doctor and an allied health professional. These are accompanied by an expert commentary recognising the important role of junior doctors in promoting patient safety provided by Prof. Joe Ibrahim.
Editorial Content
- 00:00 Commentary #1: Views from the inside
- 04:44 Commentary #2: Views from the outside
- 09:24 Commentary #3: Teams over five decades
- 14:20 Expert Commentary #2: Junior medical staff and patient safety
- 17:58 Comments from our peers
Welcome to Episode Eight of our Podcast Series. This is the first part of a two-part collection featuring material from our January 2022 print edition of the Future Leaders Communiqué.
A core element of the success in providing the healthcare our patients deserve is "teamwork" – the theme of this two-part podcast. In this first part, we present two case reports reflecting on the importance of communication within teams. The case reports are complemented by an expert commentary from Dr Shelly Jeffcott entitled ‘Dysfunctions affecting teams and teamwork’.
Episode Contents
- 00:00 Editorial
- 04:24 Case #1 Closing the loop
- 08:26 Case #2 It’s all too confusing
- 14:04 Expert Commentary #1: Dysfunctions affecting teams and teamwork
Welcome to Episode Seven of the Clinical Communiqué podcast, titled Paediatric Appendicitis.
This podcast is based on the September 2021 edition of the Clinical Communiqué.
In this podcast episode we look at paediatric appendicitis - the most common cause of acute abdomen in children, and we describe cases where delays in diagnosis and treatment tragically resulted in death.
The expert commentary by paediatric surgeon Dr Susan Adams, offers a pragmatic and insightful approach to the assessment of children with abdominal pain, with key points that help to raise awareness of the most reliable red flags in diagnosing appendicitis.
Episode Contents
- 04:33 minutes Editorial by Dr Nicola Cunningham
- 10:28 minutes Case #1: A paediatric perforation
- 21:10 minutes Case #2: Hoofbeats aren’t always horses
- 30:02 minutes Expert Commentary by Dr Susan Adams: Children get tummy aches
Welcome to Episode Ten of our podcast series. This features material from our November 2021 print edition of the Residential Aged Care Communiqué. This podcast focusses on the death of a resident from inadvertent poisoning.
The case encompasses the supply and storage of chemical agents, the roles and intersection of the clinical, personal care and domestic staff, as well as the emergency management response, and importance of verbal and written communication.
The commentary “We have seen it all before” highlights the lessons from this case were already known and described in past editions archived in our library of Residential Aged Care Communiqués.
Episode Contents
- 01:27 minutes Editorial
- 03:53 minutes Case: Managing poisoning, maintaining pose
- 16:36 minutes Commentary: We have seen it all before
Welcome to Episode Seven of our podcast series. This features material from our October 2021 print edition of the Future Leaders Communiqué.
This podcast explores the importance of communication, clinician accountability and ethical practice at all stages of the health professional-patient relationship. This is explored through the case of a patient diagnosed with metastatic cancer who died in acute and unexpected circumstances.
There are two commentaries, the first discusses the complexity and life-long need to continue developing communication skills and the second explores the ethical concerns surrounding clinician accountability.
Episode Contents
- 00:00 minutes Introduction
- 01:12 minutes Guest editorial by Dr Emily Lin
- 05:11 minutes Editorial by Dr Brendan Morrissey
- 8:33 minutes Case: Prioritising closure and disclosure
- 23:24 minutes Expert Commentary: Agility in clinical communication: a critical lifelong learning for all doctors by Professor Michelle Leech
- 29:57 minutes Expert Commentary: The ethics of clinician accountability in healthcare practice by Professor Justin Oakley
- 40:09 minutes Comments From Our Peers
Welcome to Episode Nine of our podcast series. This features material from our August 2021 print edition of the Residential Aged Care Communiqué. This podcast focusses on harm resulting from failures to listen carefully to family concerns. We present two cases where earlier attention and prompt responses to concerns raised by family may have altered the outcomes. Our expert commentary explains the online education and training programs designed for the residential aged care sector in particular learning about recognising imminent dying and preparing for the death of a resident.
Episode Contents
- 01:47 minutes Editorial
- 03:04 minutes Case #1: Ryan's rule and aged care
- 12:42 minutes Case #2: Inappropriate discharge
- 28:24 minutes Expert Commentary: Online education - recognising and responding when a palliative approach to care is needed
This episode of the Future Leaders Communiqué podcast presents the coroner’s case of Mr A, a 53-year-old man admitted to hospital with severe neck pain who was found dead in his hospital bed three days later. The episode examines two topics central to patient safety: iatrogenic injury, and barriers to escalation of care. The content is based on the July 2021 print edition, guest-edited by Dr Kate Charters.
Episode Contents
- 01:27 minutes Introduction
- 02:30 minutes Guest editorial by Kate Charters
- 07:56 minutes Editorial by Dr Brendan Morrissey
- 12:36 minutes Case report: Prioritising closure and disclosure
- 29:30 minutes Expert Commentary: Don't give more if it makes them snore by Dr Anna Korin, Emergency Medicine Physician Alfred Health
- 38:22 minutes Expert Commentary: Time to extend our medication safety net by Anne Leversha, Senior Lecturer, Monash University, Faculty of Medicine, Nursing & Health Sciences
- 45:32 minutes Comments From Our Peers
Welcome to episode six of the Clinical Communiqué podcast, titled 'Access Block'.
This podcast is based on the June 2021 edition of the Clinical Communiqué.
In this podcast episode we look at the problem of access block, a major barrier to delivering safe and timely care to patients in hospitals. We present four cases that demonstrate how the negative consequences of access block are far-reaching and affect every stage of a patient’s journey through the healthcare system.
Our expert commentary is about the lessons learned from the cases in this episode, and looks at the role every clinician can play in addressing such a systemic and pervasive and preventable problem.
Episode Contents
- 04:15 minutes Editorial by Dr Nicola Cunningham
- 10:35 minutes Case #1: Alone in a crowded space
- 20:03 minutes Case #2: The long wait
- 27:44 minutes More on the matter by Dr Nicola Cunningham: Outing the problem
- 34:53 minutes Expert Commentary by Dr Simon Judkins: A system under pressure
Welcome to Episode Eight of our podcast series. This features material from our May 2021 edition of the Residential Aged Care Communiqué. This podcast focuses on harm resulting from resident-on-resident interactions. We present two cases where the deaths occurred and an expert commentary which explains the role of Dementia Support Australia, an organisation that provides clinical support in managing complex behaviours of people with dementia. Our narrator for this episode is Will Thomas.
Episode Contents
- 03:23 minutes Editorial
- 05:34 minutes Case #1: In my room
- 14:09 minutes Case #2: Not so Great Expectations
- 28:24 minutes Expert Commentary #1: Who do I call? DBMAS
- 34:08 minutes Expert Commentary #2: A geriatrician talks to a psychiatrist
This podcast of the Future Leaders Communiqué presents a case based on an inquest into the death of a pregnant woman who presented to an emergency department with ‘rib pain’, only to later die of an undiagnosed pulmonary embolism.
The content of the podcast is based on our April 2021 print edition, with Dr Vincent Wong as guest editor. In this podcast, we have expert commentaries describing what clinicians can do to recognise the limitations of their clinical experience, and how best to utilise the safety net of senior supervision.
Episode Contents
- 01:29 minutes Introduction
- 04:34 minutes Guest editorial by Dr Vincent Wong, editorial by Dr Brendan Morrissey
- 10:50 minutes Case Report: How do you know when you need to ask for help?
- 25:42 minutes Expert Commentary: Be wise and confess to ignorance by Dr Nhi Nguyen
- 34:29 minutes Expert Commentary: Keeping an eye on junior doctors’ clinical blindspots by Associate Professor Julia Harrison
- 41:50 minutes Comments From Our Peers
Welcome to our fifth podcast episode based on the March 2021 edition of the Clinical Communiqué.
In this podcast episode we will hear about deaths due to carbon monoxide poisoning – a gas produced by the incomplete combustion of carbon-based compounds. Carbon monoxide is often referred to as the ‘silent killer’ because it is colourless, odourless, tasteless, non-irritating, and extremely toxic. Carbon monoxide poisoning is an entirely preventable illness, and if identified early enough, is wholly reversible.
Episode Contents
- 05:28 minutes Editorial
- 10:20 minutes Case #1: A poisonous adventure
- 16:35 minutes Case #2: The paradox of negative pressure
- 23:08 minutes More on the matter: Outing the problem
- 30:21 minutes Expert Commentary: Carbon monoxide toxicity: a concise and practical overview of the pathophysiology, clinical features, and treatment of patients with carbon monoxide toxicity by Dr. Matthew Spotswood
Welcome to Episode Seven of this podcast series which features material from our February 2021 edition of the Residential Aged Care Communiqué.
This podcast focuses on medication safety in aged care homes. We present two cases where the deaths of aged care facility residents were investigated by the Coroners Court. Dr. Huong Nguyen gives us a case precis of a death involving missed doses of anticonvulsant medication. This is followed by Dr. Supriya Rama Krishnan’s case precis of a death involving inadvertent administration of the wrong medication.
The podcast concludes with a commentary on a systems approach to improve medication management by two experts from Safer Care Victoria, Dr. Raphaela Schnittker, a Human Factors Specialist, and Ms. Jen Morris.
Episode Contents
- 02:29 minutes Editorial
- 04:48 minutes Case #1: The fax of the matter
- 14:51 minutes Case #2: An interrupted drug round
- 22:58 minutes Expert Commentary: Human Factors and Medication Safety
This podcast of the Future Leaders Communiqué presents a case based on an inquest into the death of a young woman from suicide who had present on multiple occasion to different health services seeking help. All to no avail.
The content of the podcast is based on our January 2021 print edition which was with Dr Daniel Grose as guest editor. In this podcast we have a contribution from the family and expert commentaries describing what clinicians could do to mitigate the risk of error in assessing and managing patients presenting with mental health issues.
Episode Contents
- 01:29 minutes Introduction
- 04:34 minutes Guest editorial by Dr Daniel Grose, editorial by Dr Brendan Morrissey and guest commentary by Violet Tregonning
- 10:50 minutes Case Report Dr Daniel Grosse “Who cares?”
- 25:42 minutes Expert Commentary by Associate Professor Jonathan Knott “The system is broken”
- 34:29 minutes Expert Commentary by Dr Evan Symons “Care of the acutely suicidal patient”
- 41:50 minutes Comments From Our Peers
This podcast of the Clinical Communiqué features the important issue of clinical handover of patients to primary care. We present two cases where the multiple steps required to safely discharge the patient from hospital to home were inadequate or incomplete, leading to fatal consequences.
The content of the podcast is based on our December 2020 print edition of the Clinical Communiqué and includes an expert commentary by an Australian group of clinicians leading the way in improving clinical handover to primary care.
Episode Contents
- 03:21 minutes Editorial
- 09:46 minutes Case #1: Don’t ask, don’t tell
- 23:54 minutes Case #2: An incomplete picture
- 35:27 minutes Expert Commentary: Clinical handover to primary care – Why reframing ‘discharge summaries’ as ‘clinical handovers’ matters by Dr Katrina McLean, Dr Michael Rice, Dr Tim Leeuwenburg, and Dr Nick Tellis
This first part of this podcast of the Residential Aged Care Communiqué Dr Chelsea Baird describes several case reports of COVID19 in older persons highlighting the atypical presentations and challenges of management.
The second part of the podcast provides brief summaries of recent important inquiries into the management of COVID-19 outbreaks in aged care.
Episode Contents
- 03:21 minutes Editorial
- 06:49 minutes Case #1 “That’s not COVID-19”
- 11:42 minutes Case #2 “Challenges of isolation and environment”
- 17:26 minutes Case #3 “COVID-19 and mental health”
- 19:02 minutes Report into Newmarch House COVID-19 Outbreak
- 27:28 minutes Amnesty International’s report “As If Expendable”
- 33:20 minutes Royal Commission’s “Aged care and COVID-19: a special report”
- 36:12 minutes Ontario’s “Long-Term Care COVID-19 Commission”
- 38:19 minutes Clinical Screening Tool for COVID-19 in Residential Aged Care Facilities
This podcast of the Future Leaders Communiqué presents a case based on an inquest into the death of a six-year-old boy from a readily treatable illness due to inadequate documentation, poor communication, and sub-standard care.
The content of the podcast is based on our October 2020 print edition with Dr Samantha Walker as guest editor. In this podcast we explore what the quality of clinical documentation and handover reveals about the treating team, and how improving it will reflect better on our professionalism, in addition to helping our patients.
Episode Contents
- 02:46 minutes Guest Editorial with Dr Samantha Walker
- 08:45 minutes Editorial with Dr Brendan Morrissey
- 11:50 minutes Case Report Dr Samantha Walker “Write as though a person's life depends on it”
- 34:38 minutes Expert Commentary by Dr Nick Thies “Medical record writing is an art which can enhance knowledge and experience and contribute to efficient and safe patient care”
- 44:39 minutes Expert Commentary by Rocky Ruperto, “The art of describing the case: Communication and clinical record-keeping”
- 54:04 minutes Comments From Our Peers
This podcast of the Clinical Communiqué presents four expert commentaries that offer guidance to health care workers on establishing and maintaining psychological safety during the pandemic. Dr Jesse Zanker writes a compelling piece about self-care and recognising vicarious trauma during COVID-19, and Dr Michelle Ananda-Rajah astutely outlines the importance of framing personal protective equipment and health care worker safety within an occupational health and safety lens. Dr Mya Cubitt and Dr Carmel Crock present their humanising perspective on leading a profession at the frontline, and Dr Neil Cunningham discusses risk and moral injury with insightful tips on creating a safe environment at work. They bring a wealth of knowledge and their own personal accounts of the pandemic to their commentaries.
Episode Contents
- 03:21 minutes Editorial
- 09:46 minutes Expert Commentary by Dr Jesse Zanker “Our safety is our patients’ safety”
- 23:54 minutes Expert Commentary by Dr Michelle Ananda-Rajah “Flattening the hierarchy to keep health care workers safe”
- 35:27 minutes Expert Commentary Dr Neil Cunningham “Risk, moral injury, and decision-making in the time of COVID-19”
- 51:06 minutes Expert Commentary Dr Mya Cubitt and Dr Carmel Crock, “Health care leadership in COVID-19; Getting better at getting better, together”
This podcast of the Residential Aged Care Communiqué presents a complex case where a resident was treated with bleach bath. It has multiple dimensions including pain management, an organisations capability in the use of off-script medication and when good intentions lead to harm. Dr Shelly Jeffcott, an expert in human factors psychology explains the importance of building our non-technical skills. Angela Casey reinforces the importance of pain management especially in persons with dementia and an experienced pharmacist in aged care Dr Natali Jokanovic discuss the merits of off-label therapy and medication management.
Episode Contents
- 02:49 minutes Editorial
- 04:43 minutes Case Report Dr Chelsea Baird“Two halves do not equal one”
- 22:10 minutes Expert Commentary by Dr Shelly Jeffcott, “Building our non-technical skills”
- 29:59 minutes Expert Commentary by RN Angela Casey “Recognition and reporting of pain and changing health status of residents”
- 36:34 minutes Expert Commentary by Dr Natali Jokanovic“Off-label therapy and medication management”
The focus of this Podcast is how health care professionals can provide better care for individuals of culturally and linguistically diverse (CALD) backgrounds. We present a sobering example of patient harm due to communication failures - the case of Mr AD, a 71 year old man who did not speak English, who died of post-operative complications following discharge from hospital after elective surgery.
In this Podcast we explore two cases where death occurred in secure settings - a correctional facility and a mental health facility. As the details unfolded at inquest, it became apparent that the usual layers of complexity that exist in providing care to patients with multiple physical and mental health co-morbidities in acute hospital settings were magnified.
This podcast draws on the Residential Aged Care Communiqué published in May 2020 and we again examine the COVID-19 pandemic on aged care.
We are at risk of becoming complacent and underestimating the true scale of the pandemic. In this podcast we examine outbreaks of COVID-19 in aged care, debate whether it is preferable to transfer residents to an acute hospital. We also explore why more than the usual infection control techniques are needed.
This podcast draws on the COVID 2020 special edition of the Future Leaders Communiqué (released in April 2020) which examined the COVID-19 pandemic and the role of recent graduate health professionals. Dr Brendan Morrissey identifies and reflects upon the wealth of knowledge our experts have shared with us over the years and focusses on those most prescient to the challenges to come. We wish to champion foundations of good practice; such as effective communication, collaborative care, the use of protocols in healthcare organisations, and systems of support for junior health professionals.
In this episode:
- Editorial
- Communication
- Collaborative Care
- Protocols in Healthcare Organisations
- Systems of Support for Junior Doctors
- Comments from Our Peers
This podcast draws on the COVID 2020 special edition of the Clinical Communiqué (released in March 2020) which examined the COVID-19 pandemic and acute health care. Dr Nicola Cunningham has selected six past editions of the Clinical Communiqué that address key themes for improving patient safety. We recall the expert commentaries for each of those themes and reflect on a few practical considerations that are specific to managing COVID-19 patients. We need to utilise lessons already learned to be proactive in our environment, nimble in our response, and adapt quickly in our clinical encounters to keep our patients and ourselves safe.
In this episode:
- Editorial
- Clinical Decision-Making
- Working in Teams
- Transferring Critically Unwell Patients
- Communication in the Workplace
- Fixation Errors
- Learning from Influenza Epidemics
- The Polygon of Patient Safety
This podcast draws on the Residential Aged Care Communiqué edition published in February 2018 examining the most common cause of resident deaths from injury, that is, falls.
The two cases in this edition highlight the need for robust post-falls management practice, greater awareness of circumstances that lead to falls, and the importance of good communication and documentation. The expert commentaries are from clinicians in practice: a senior occupational therapist, a senior physiotherapist, and a geriatrician.
In this episode:
- Editorial
- Case #1: First impressions
- Case #2: Keeping warm in the sun
- Commentary #1: An occupational therapist’s view
- Commentary #2: A physiotherapist’s perspective
- Commentary #3: Cervical-spine injuries in the elderly
In this podcast Professor Joseph Ibrahim interviews three guests from the United States of America who provide their perspectives on work and life relevant to health and aged care. We touch on topics examining the role of the individual, the group, and broader society, all with a focus on helping us to deliver better care for patients, residents and the general community.
As we produced this podcast during the COVID-19 pandemic in the USA, the interviews all touch on this topic. Our first segment is titled ‘New York, New York or Why people trump money’. Our guest is Priyesh Upreti, a senior executive with KPMG who is living and working in New York City. Our second segment is ‘Normalisation of deviance or Why turning a blind eye is dangerous.’ Our guest is Professor John Banja from the Department of Rehabilitation Medicine and Center for Ethics at Emory University in Atlanta. Our third and final segment is titled ‘Pandemics or The textbook comes alive’. Our guest is Dr Nita Madhav, the Chief Executive Officer at Metabiota who has researched and published about pandemics.
In this episode:
- New York, New York or why people trump money
- Normalisation of deviance or why turning a blind eye is dangerous
- Pandemics or the textbook comes alive
This podcast draws on the special edition of the Residential Aged Care Communiqué published in April 2020 examining the COVID-19 pandemic on aged care. COVID-19 has changed the world as we know it and the challenges ahead for nursing homes is profound. We have all seen the distressing pictures from Spain where nursing homes were abandoned, and the military had to move in to provide the support. The devastation and deaths of older people living in nursing homes was evident throughout the world in high income countries with robust health systems such as France, Italy, Spain, United Kingdom, Canada and United States of America.
As a sector we are amazingly robust in our capacity to care, problem solve and work together. We need those qualities now more than ever. In this podcast we present a sobering case report from the United States of America, the aspects of aged care that are not so obvious to consider in the COVID-19 pandemic, and four potential scenarios that for many across the world have become a reality to consider in planning a response for nursing homes.
In this episode:
- Editorial
- Case Report
- Aspects of COVID-19 that are not so obvious
- Meeting the challenges ahead requires speculation