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

• 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

• 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 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

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

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