Vanessa Anderson Case: Improving Communication in Healthcare Settings
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Case Study
AI Summary
This case study delves into the tragic case of Vanessa Anderson, a sixteen-year-old who died due to a series of medical errors and communication breakdowns within a hospital setting. The analysis highlights the critical importance of effective communication among healthcare providers, proper documentation, and robust hospital systems to ensure patient safety and quality care. The case underscores how failures in these areas, including inadequate supervision of junior staff, lack of clear pain management guidelines, and miscommunication regarding medication and patient transfers, contributed to Vanessa's demise. The coroner's findings led to significant changes in hospital policies and training programs, emphasizing the need for better communication, comprehensive patient assessments, and improved management of pain and medication. The role of registered nurses in detecting and reporting clinical deterioration through systematic assessments and monitoring of vital signs is also examined, reinforcing the necessity of adhering to nursing standards and fostering strong patient-nurse relationships. Desklib offers resources for students to further explore similar cases and learn from past healthcare incidents.
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Running head: VANESSA ANDERSON
1
The Case of Vanessa Anderson
Name
Institution
1
The Case of Vanessa Anderson
Name
Institution
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VANESSA ANDERSON
2
The Case of Vanessa Anderson
Introduction
Vanessa Anderson was a sixteen year old who was admitted at Hornsby Hospital in
Sydney following an accident at the charity golf day that she had participated in. She had been
hit behind the right ear with a golf ball and a CT scan had showed a depressed skull and
confusions. She also presented vomiting and disorientation. A series of events that followed her
admission at the hospital eventually led to the death of the young girl. Vanessa’s death was a
result of human error and negligence by the care givers. It brought to light the importance good
hospital systems that would promote good communication in an effort to promote top quality
care. Any breakdown in communication can lead to serious complications and death as
evidenced by the case of Vanessa Anderson.
Discussion
The Importance of Good Communications as seen in the case of Vanessa Anderson
According to a report by CRICO, who are patient safety experts, communication errors
are a result of unrecorded information, misdirection, case of where information was never
received, never retrieved or simply ignored (White, 2016, para 3). They pointed out the fact that
miscommunication does not only happen when patients do not fully understand their doctors. It
can also happen between the careers themselves if at any given point the aforementioned errors
occur. The nurse bears a huge chunk or responsibility when it comes to ensuring that proper
communication takes place. This is due to the fact that they are the primary caregivers and are
2
The Case of Vanessa Anderson
Introduction
Vanessa Anderson was a sixteen year old who was admitted at Hornsby Hospital in
Sydney following an accident at the charity golf day that she had participated in. She had been
hit behind the right ear with a golf ball and a CT scan had showed a depressed skull and
confusions. She also presented vomiting and disorientation. A series of events that followed her
admission at the hospital eventually led to the death of the young girl. Vanessa’s death was a
result of human error and negligence by the care givers. It brought to light the importance good
hospital systems that would promote good communication in an effort to promote top quality
care. Any breakdown in communication can lead to serious complications and death as
evidenced by the case of Vanessa Anderson.
Discussion
The Importance of Good Communications as seen in the case of Vanessa Anderson
According to a report by CRICO, who are patient safety experts, communication errors
are a result of unrecorded information, misdirection, case of where information was never
received, never retrieved or simply ignored (White, 2016, para 3). They pointed out the fact that
miscommunication does not only happen when patients do not fully understand their doctors. It
can also happen between the careers themselves if at any given point the aforementioned errors
occur. The nurse bears a huge chunk or responsibility when it comes to ensuring that proper
communication takes place. This is due to the fact that they are the primary caregivers and are
VANESSA ANDERSON
3
often in direct contact with the patient. They RN facilitate communication between the patient
and physician showing how important their involvement is (Lyndon et al, 2011, para 13).
Nurses have the responsibility of creating a favorable environment for the patients in
order to ensure that there is open communication between them (Stone et al, 2008, para 18).
They ought to take their time given that some patients could be incapacitated, nervous or upset
and thus unwelcoming or rushed conversations. Choosing a private area free of distractions may
also do the patient good since they will be assured of the confidentiality and protection of their
personal information (TUNM, 2018, para 13). There are many benefits that follow a direct and
open communication between nurses and patients. First, it provides an opportunity for
individualized care. This is because a nurse who is aware of the challenges and concerns that are
unique to their patients will be in a good position to act as their advocate so as to ensure they
receive the correct attention and treatment is given (Kuokota, 2014, p. 7). Nurses must advocate
equal time to hands on care and documentation. This is because the two are components of
patient care.
The fact that Vanessa Anderson lacked personalized treatment is quite evident. Upon her
admission to the hospital, she was transferred to Royal North Shore Hospital in Sydney. She had
no nurse following this up which eventually leads to miscommunication by the Registrar who
informs Dr. Little that she is to be transferred to Westmead Children’s hospital. Even then the
absence of a caregiver is quite obvious owing to the fact that Dr. Little was not informed that
Vanessa was under her care, leave alone informing him that she was supposed to be transferred
to another hospital. In addition to a lack of personalized care and treatment this shows a lack of
proper communication channels between the various healthcare providers in the hospital. If
3
often in direct contact with the patient. They RN facilitate communication between the patient
and physician showing how important their involvement is (Lyndon et al, 2011, para 13).
Nurses have the responsibility of creating a favorable environment for the patients in
order to ensure that there is open communication between them (Stone et al, 2008, para 18).
They ought to take their time given that some patients could be incapacitated, nervous or upset
and thus unwelcoming or rushed conversations. Choosing a private area free of distractions may
also do the patient good since they will be assured of the confidentiality and protection of their
personal information (TUNM, 2018, para 13). There are many benefits that follow a direct and
open communication between nurses and patients. First, it provides an opportunity for
individualized care. This is because a nurse who is aware of the challenges and concerns that are
unique to their patients will be in a good position to act as their advocate so as to ensure they
receive the correct attention and treatment is given (Kuokota, 2014, p. 7). Nurses must advocate
equal time to hands on care and documentation. This is because the two are components of
patient care.
The fact that Vanessa Anderson lacked personalized treatment is quite evident. Upon her
admission to the hospital, she was transferred to Royal North Shore Hospital in Sydney. She had
no nurse following this up which eventually leads to miscommunication by the Registrar who
informs Dr. Little that she is to be transferred to Westmead Children’s hospital. Even then the
absence of a caregiver is quite obvious owing to the fact that Dr. Little was not informed that
Vanessa was under her care, leave alone informing him that she was supposed to be transferred
to another hospital. In addition to a lack of personalized care and treatment this shows a lack of
proper communication channels between the various healthcare providers in the hospital. If
VANESSA ANDERSON
4
proper communication channels were in existence, Vanessa would have been transferred to the
appropriate hospital as soon as the directive was given. Dr. Little would also have been made
aware that Vanessa was under care and would have made the right decisions at the right times
which might have saved her life.
Another importance of communication in patient care is to ensure that all caregivers who
attend to a patient have the full history and information regarding her case. Nurses are usually
held accountable by their records, professionally, legally and ethically (Wood, 2015, p. 26). It is
thus important to ensure that vitals and all relevant observations are charted not only for
accountability reasons but to also ensure that caregivers are able to identify any problems and
patterns and adequately plan for care (Twomey & Cummins, 2010, p. 5). In Vanessa Anderson’s
case, the nurses failed to record observations after a second round. Medication charting was also
missing. Dr. Ismail who did a round with Vanessa was not aware of the fact that she had ordered
for Panadiene Forte. She thought that regular Panadiene is what had been administered to her.
She was also not aware that analgesia was to be determined by the neurosurgical consultant or
registrar. Dr. Ismail charts Vanessa for increased Endone after she complained of persistent pain.
Her failure to record a maximum dosage was fatal. This brings into light another error in
communication that show a flaw in medication charting by the caregiving staff.
The coroner’s Findings and how they became a catalyst for change
The coroner identified system failures that contributed to Vanessa’s demise. She noted
that there was a lack of proper admission procedure, inadequate supervision of junior staff,
communication problems as discussed above, location of patient away from the nurses’ station
and in the adult section and lack of a rigorous neurological observation (Milovanovich, 2008, p.
4
proper communication channels were in existence, Vanessa would have been transferred to the
appropriate hospital as soon as the directive was given. Dr. Little would also have been made
aware that Vanessa was under care and would have made the right decisions at the right times
which might have saved her life.
Another importance of communication in patient care is to ensure that all caregivers who
attend to a patient have the full history and information regarding her case. Nurses are usually
held accountable by their records, professionally, legally and ethically (Wood, 2015, p. 26). It is
thus important to ensure that vitals and all relevant observations are charted not only for
accountability reasons but to also ensure that caregivers are able to identify any problems and
patterns and adequately plan for care (Twomey & Cummins, 2010, p. 5). In Vanessa Anderson’s
case, the nurses failed to record observations after a second round. Medication charting was also
missing. Dr. Ismail who did a round with Vanessa was not aware of the fact that she had ordered
for Panadiene Forte. She thought that regular Panadiene is what had been administered to her.
She was also not aware that analgesia was to be determined by the neurosurgical consultant or
registrar. Dr. Ismail charts Vanessa for increased Endone after she complained of persistent pain.
Her failure to record a maximum dosage was fatal. This brings into light another error in
communication that show a flaw in medication charting by the caregiving staff.
The coroner’s Findings and how they became a catalyst for change
The coroner identified system failures that contributed to Vanessa’s demise. She noted
that there was a lack of proper admission procedure, inadequate supervision of junior staff,
communication problems as discussed above, location of patient away from the nurses’ station
and in the adult section and lack of a rigorous neurological observation (Milovanovich, 2008, p.
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VANESSA ANDERSON
5
32). The coroner expressed the dire situation by stating that The Task "As Deputy State
Coroner for the past six years I have regrettably presided over many inquests involving
deaths in hospitals. In many of these cases one error or omission sometimes a serious one
led to death, however, I have never seen a case such as Vanessa's in which almost every
conceivable error or omission was detected and those errors continued to build one on top
of the other” (Milovanovich, 2008, p. 4). Several changes were put in place at the RNSH
hospital and in other NSW hospitals following the observations by the coroner. The first change
was that teenage patients needed to be nursed as close as possible to the nursing station to
facilitate personalized and better care. A policy was also prepared for the nursing staff on the
issue of performing routine observation on the patients. This was further emphasized by
providing for continuous education on the importance of documentation of all orders concerning
the patient (NSW, 2008).
Training of various staff in various capacities was also introduced at the hospital.
Guidelines that were to be used by the junior staff in notifying consultants were developed.
Training of Junior Medical officers was also modified to include communication with consulting
officers. Opioid prescribing and pain management training was further done for the in house
nurses (Graema & Dwyer, 2009, p. 81). There was also a change in the management style of the
house in an effort to promote quality twenty four hour care. Adequate cover for periods when the
registrar is away was introduced and documentation emphasized in such instances. The acute
pain management policy was also modified to include the fact that the decision regarding the
prescription of analgesia outside the available guidelines can only be made by neurosurgical
registrar or consultant (NSW, 2008). These changes left nothing to chance seeing that many
5
32). The coroner expressed the dire situation by stating that The Task "As Deputy State
Coroner for the past six years I have regrettably presided over many inquests involving
deaths in hospitals. In many of these cases one error or omission sometimes a serious one
led to death, however, I have never seen a case such as Vanessa's in which almost every
conceivable error or omission was detected and those errors continued to build one on top
of the other” (Milovanovich, 2008, p. 4). Several changes were put in place at the RNSH
hospital and in other NSW hospitals following the observations by the coroner. The first change
was that teenage patients needed to be nursed as close as possible to the nursing station to
facilitate personalized and better care. A policy was also prepared for the nursing staff on the
issue of performing routine observation on the patients. This was further emphasized by
providing for continuous education on the importance of documentation of all orders concerning
the patient (NSW, 2008).
Training of various staff in various capacities was also introduced at the hospital.
Guidelines that were to be used by the junior staff in notifying consultants were developed.
Training of Junior Medical officers was also modified to include communication with consulting
officers. Opioid prescribing and pain management training was further done for the in house
nurses (Graema & Dwyer, 2009, p. 81). There was also a change in the management style of the
house in an effort to promote quality twenty four hour care. Adequate cover for periods when the
registrar is away was introduced and documentation emphasized in such instances. The acute
pain management policy was also modified to include the fact that the decision regarding the
prescription of analgesia outside the available guidelines can only be made by neurosurgical
registrar or consultant (NSW, 2008). These changes left nothing to chance seeing that many
VANESSA ANDERSON
6
small errors eventually lead to fatalities as seen in Vanessa’s case. They trickled down to the
Australian Health system introducing an aspect of better communication, care and management
in the Australian Health system.
Role of the Registered Nurse in the Detection and Reporting of Clinical Deterioration
Notably, nurses are required to accurately and comprehensively conduct assessments in a
systematic manner. In doing so, and as the nursing standards necessitate, they analyze
information and data pertaining to patients and afterwards, they communicate the outcomes in
accordance with the facets of the practice. Moreover, the assessments that are conducted by the
registered nurse should be holistic as well as culturally appropriate. Aside from the wide range of
techniques required in assessments and analyses, RNs are also required to work in partnerships
in order to identify factors or potential effects that may be detrimental to the diverse patient
populations that are under their care. Such an initiative would prove to be critical in determining
the action plans or referrals to be taken so as to protect the well-being of their patients.
Similarly, and as revealed by studies, patient assessments proved to be one of the key
factors that influenced RNs recognition and response to patient deterioration. Additionally, to
further facilitate this process, RNs ought to know the patient by developing formidable patient-
nurse relationships, educate themselves and also be aware of the environmental factors that
might impact the patient’s health (Massey, Chaboyer & Anderson, 2017, p. 8). In responding to
the deterioration of the patient’s health studies also reveal that nurses should strive to develop
non-technical skills, improve access to support and exhibit negative emotional responses. In this
light, it becomes apparent that these factors and practice coincide with the nursing standard
requirements which mandate that nurses should accurately assess their patients and also work in
6
small errors eventually lead to fatalities as seen in Vanessa’s case. They trickled down to the
Australian Health system introducing an aspect of better communication, care and management
in the Australian Health system.
Role of the Registered Nurse in the Detection and Reporting of Clinical Deterioration
Notably, nurses are required to accurately and comprehensively conduct assessments in a
systematic manner. In doing so, and as the nursing standards necessitate, they analyze
information and data pertaining to patients and afterwards, they communicate the outcomes in
accordance with the facets of the practice. Moreover, the assessments that are conducted by the
registered nurse should be holistic as well as culturally appropriate. Aside from the wide range of
techniques required in assessments and analyses, RNs are also required to work in partnerships
in order to identify factors or potential effects that may be detrimental to the diverse patient
populations that are under their care. Such an initiative would prove to be critical in determining
the action plans or referrals to be taken so as to protect the well-being of their patients.
Similarly, and as revealed by studies, patient assessments proved to be one of the key
factors that influenced RNs recognition and response to patient deterioration. Additionally, to
further facilitate this process, RNs ought to know the patient by developing formidable patient-
nurse relationships, educate themselves and also be aware of the environmental factors that
might impact the patient’s health (Massey, Chaboyer & Anderson, 2017, p. 8). In responding to
the deterioration of the patient’s health studies also reveal that nurses should strive to develop
non-technical skills, improve access to support and exhibit negative emotional responses. In this
light, it becomes apparent that these factors and practice coincide with the nursing standard
requirements which mandate that nurses should accurately assess their patients and also work in
VANESSA ANDERSON
7
partnerships so as to improve the health and identify potential factors that may be harmful to
their patients’ health. Standard 4 of the Registered Nurse standards for practice stipulates
(the Nursing and Midwifery Board of Australia, 2016,p 4) that "RNs will accurately
conduct comprehensive and systematic assessments. They analyze information and data
and communicate outcomes as the basis for practice.”
RNs also have a critical role to play in the detection and reporting of clinical deterioration
by monitoring vital signs in patients. Ideally, this practice has proven to conform to the
requirements of important nursing assessments. However, RNs have fallen short of this practice.
In these cases, research reveal that nurses tend to overlook this procedure and its significance in
detecting patient deterioration but instead, RNs often perform vital signs monitoring only as part
of the routine. Among the reasons for doing so have is the heavy workload that they face (Mok,
Wang & Liaw, 2015, p. 98).Nonetheless, such evidence affirms the fact that it is the role of
nurses to ensure that perform vital signs monitoring in order to facilitate detection and reporting
of clinical deterioration (Mok et al, 2015, p. 209)..
The contributing Factors to Vanessa’s Death
A death is usually reported to the coroner if the circumstances surrounding it are as
outlined in section Section 13 of the coroner’s ACT. Vanessa died suddenly, unexpectedly in
circumstances where the doctor was prohibited from issuing a certificate of the cause of death.
The coroner identified a number of issues that possibly contributed to Vanessa’s death. The first
is that RNSH lacked a proper pain management guideline. This led to an increased likelihood of
prescribing multiple opioid medications that might have led to respiratory depression given that
Vanessa was opioid naïve. Multiple team involvement in pain management beyond the primary
7
partnerships so as to improve the health and identify potential factors that may be harmful to
their patients’ health. Standard 4 of the Registered Nurse standards for practice stipulates
(the Nursing and Midwifery Board of Australia, 2016,p 4) that "RNs will accurately
conduct comprehensive and systematic assessments. They analyze information and data
and communicate outcomes as the basis for practice.”
RNs also have a critical role to play in the detection and reporting of clinical deterioration
by monitoring vital signs in patients. Ideally, this practice has proven to conform to the
requirements of important nursing assessments. However, RNs have fallen short of this practice.
In these cases, research reveal that nurses tend to overlook this procedure and its significance in
detecting patient deterioration but instead, RNs often perform vital signs monitoring only as part
of the routine. Among the reasons for doing so have is the heavy workload that they face (Mok,
Wang & Liaw, 2015, p. 98).Nonetheless, such evidence affirms the fact that it is the role of
nurses to ensure that perform vital signs monitoring in order to facilitate detection and reporting
of clinical deterioration (Mok et al, 2015, p. 209)..
The contributing Factors to Vanessa’s Death
A death is usually reported to the coroner if the circumstances surrounding it are as
outlined in section Section 13 of the coroner’s ACT. Vanessa died suddenly, unexpectedly in
circumstances where the doctor was prohibited from issuing a certificate of the cause of death.
The coroner identified a number of issues that possibly contributed to Vanessa’s death. The first
is that RNSH lacked a proper pain management guideline. This led to an increased likelihood of
prescribing multiple opioid medications that might have led to respiratory depression given that
Vanessa was opioid naïve. Multiple team involvement in pain management beyond the primary
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VANESSA ANDERSON
8
care that was present due to a lack of guidelines and clearly defined responsibilities for treating
pain and prescribing analgesia. The prescription of analgesia might have contributed further to
respiratory failure in Vanessa’s case. The coroner also observed that there was unrealistic goals
for pain relief for Vanessa given the level of knowledge and underst6anding of the clinicians
from various disciplines. This led to an escalation in prescribing contributing to respiratory
failure. Lastly, he noted that an increase in dosage and frequency of analgesia being prescribed
resulting from illegibility of a written order may further have contributed to respiratory
depression (Milovanovich, 2008, p. 34).
A gap was identified between health service management and the clinicians by the
Garling report (Stewart, 2009). This issue contributed to Vanessa’s death given that there was no
proper coordination of healthcare providers in the case. The junior clinician attending to her also
lacked the skillset necessary to make an informed decision about her case. The report
recommended a change in management by introducing an institute for Clinical Education and
training which would develop and carry out leadership training for clinicians (RACMA, 2013, p.
3). This would solve the gap that had been identified in clinical leadership (Joseph & Hunyor,
2008, p. 471) Clinical leadership would further be reinforced by introducing the position of
“Executive clinical director in all NSW clinical Centers. This individual would be responsible for
improving the clinical practice in their centers, acts a spokesperson among other things (Graema
& Dwyer 2009, p. 84). The report also identified a gap in interdisciplinary healthcare teams.
Vanessa was transferred to RNSH, her doctor received the news way later with a different
hospital destination, Westmead Children’s Hospital. This shows a lack of of proper
communication in the relevant department. Some of the attendants that were supposed to be
8
care that was present due to a lack of guidelines and clearly defined responsibilities for treating
pain and prescribing analgesia. The prescription of analgesia might have contributed further to
respiratory failure in Vanessa’s case. The coroner also observed that there was unrealistic goals
for pain relief for Vanessa given the level of knowledge and underst6anding of the clinicians
from various disciplines. This led to an escalation in prescribing contributing to respiratory
failure. Lastly, he noted that an increase in dosage and frequency of analgesia being prescribed
resulting from illegibility of a written order may further have contributed to respiratory
depression (Milovanovich, 2008, p. 34).
A gap was identified between health service management and the clinicians by the
Garling report (Stewart, 2009). This issue contributed to Vanessa’s death given that there was no
proper coordination of healthcare providers in the case. The junior clinician attending to her also
lacked the skillset necessary to make an informed decision about her case. The report
recommended a change in management by introducing an institute for Clinical Education and
training which would develop and carry out leadership training for clinicians (RACMA, 2013, p.
3). This would solve the gap that had been identified in clinical leadership (Joseph & Hunyor,
2008, p. 471) Clinical leadership would further be reinforced by introducing the position of
“Executive clinical director in all NSW clinical Centers. This individual would be responsible for
improving the clinical practice in their centers, acts a spokesperson among other things (Graema
& Dwyer 2009, p. 84). The report also identified a gap in interdisciplinary healthcare teams.
Vanessa was transferred to RNSH, her doctor received the news way later with a different
hospital destination, Westmead Children’s Hospital. This shows a lack of of proper
communication in the relevant department. Some of the attendants that were supposed to be
VANESSA ANDERSON
9
taking care of Vanessa were away and no one was around to replace them showing a shortage of
caregivers at RNSH. The Garling report recommended that changes be made to ensure that the
healthcare providers with the right mix of skills are available at all timers in healthcare facilities,
annual performance reviews be conducted to keep the care givers on their toes and measures be
taken to ensure that there is no shortage of staff in hospitals (Garling, 2008, p. 3).
Conclusion
The RN has a major role to play in ensuring that patients receive the best care. They not
only need to pay close attention to the one on one interaction with the patients but should also
ensure that they put an equal amount of effort in documentation of their observations and
patient’s vitals. Communication is vital in all this as it allows for a number of things including’
personalized care and treatment for the patients, collaboration of all care givers to ensure that
correct decisions are made regarding a given case and that the patient receives the correct
treatment. It is important for organizations to offer support to all their healthcare providers given
the fact that human errors can accumulate to the point of death or fatalities as in the case of
Vanessa Anderson. It is good t0o note that the NSW healthcare facilities have implemented the
recommendations from the Coroner’s report on the case of Vanessa Anderson and the Garling
Report which sought to make the services offered by public hospitals better.
9
taking care of Vanessa were away and no one was around to replace them showing a shortage of
caregivers at RNSH. The Garling report recommended that changes be made to ensure that the
healthcare providers with the right mix of skills are available at all timers in healthcare facilities,
annual performance reviews be conducted to keep the care givers on their toes and measures be
taken to ensure that there is no shortage of staff in hospitals (Garling, 2008, p. 3).
Conclusion
The RN has a major role to play in ensuring that patients receive the best care. They not
only need to pay close attention to the one on one interaction with the patients but should also
ensure that they put an equal amount of effort in documentation of their observations and
patient’s vitals. Communication is vital in all this as it allows for a number of things including’
personalized care and treatment for the patients, collaboration of all care givers to ensure that
correct decisions are made regarding a given case and that the patient receives the correct
treatment. It is important for organizations to offer support to all their healthcare providers given
the fact that human errors can accumulate to the point of death or fatalities as in the case of
Vanessa Anderson. It is good t0o note that the NSW healthcare facilities have implemented the
recommendations from the Coroner’s report on the case of Vanessa Anderson and the Garling
Report which sought to make the services offered by public hospitals better.
VANESSA ANDERSON
10
References
Garling, P. (2008). Final report of the Special Commission of Inquiry Acute care Services in
NSW Hospitals. Retrieved from https://www.dpc.nsw.gov.au/?a=34194
Graema, S. & Dwyer, J. (2009). Implementation of the Garling Recommendations can offer
Real Hope for Rescuing the New South Wales Public Hospitals. The Medical Journal of
Australia 190 (2), 80-82.
Joseph, A. & Hunyor, S. (2008). The Royal North Shore Hospital Inquiry: an Analysis of the
implications for quality and safety in Australian Public Hospitals. The Medical Journal of
Australia 188(8), 469-472.
Koukota, L. (2014). Communication in Nursing Practice. NCBI. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990376/
10
References
Garling, P. (2008). Final report of the Special Commission of Inquiry Acute care Services in
NSW Hospitals. Retrieved from https://www.dpc.nsw.gov.au/?a=34194
Graema, S. & Dwyer, J. (2009). Implementation of the Garling Recommendations can offer
Real Hope for Rescuing the New South Wales Public Hospitals. The Medical Journal of
Australia 190 (2), 80-82.
Joseph, A. & Hunyor, S. (2008). The Royal North Shore Hospital Inquiry: an Analysis of the
implications for quality and safety in Australian Public Hospitals. The Medical Journal of
Australia 188(8), 469-472.
Koukota, L. (2014). Communication in Nursing Practice. NCBI. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990376/
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VANESSA ANDERSON
11
Lyndon, A. Zlatnik, M. G., & Wachter, R. M. (2011). Effective Physician – Nurse
Communication. NCBI. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219810/
Massey, D., Chaboyer, W., & Anderson, V. (2017). What Factors Influence Ward Nurses’
Recognition and Response to Patient Deterioration? An Integrative Review of Literature.
Nursing Open, 4(1), 6-23. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221430/
Milovanovich, M. (2008). Inquest into the Death of Vanessa Anderson. NSW Deputy State
Coroner. Retrieved from
http://www.heti.nsw.gov.au/Global/District-HETI/Westmead_coroners_court_inquest_V
anessa_Anderson.pdf
Mok, Wang, W., Cooper, S., Ang, E. N., & Liaw, S. Y. (2015). Attitudes Towards Vital Signs
Monitoring in the Detection of Clinical Deterioration: Scale Development and Survey of
Ward Nurses. International Journal for Quality in Healthcare, 27(3), 207-213. Retrieved
from https://academic.oup.com/intqhc/article/27/3/207/2357301
Mok, W. Q., Wang, W., & Liaw, S. Y. (2015). Vital Signs Monitoring to Detect Patient
Deterioration: An Integrative Literature Review. International Journal of Nursing
Practice, 2, 91-98. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26125576
Nursing and Midwifery Board. (2016). Registered Nurse Standards for practice. Retrieved from
www.nursingmidwiferyboard.gov.au
11
Lyndon, A. Zlatnik, M. G., & Wachter, R. M. (2011). Effective Physician – Nurse
Communication. NCBI. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219810/
Massey, D., Chaboyer, W., & Anderson, V. (2017). What Factors Influence Ward Nurses’
Recognition and Response to Patient Deterioration? An Integrative Review of Literature.
Nursing Open, 4(1), 6-23. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221430/
Milovanovich, M. (2008). Inquest into the Death of Vanessa Anderson. NSW Deputy State
Coroner. Retrieved from
http://www.heti.nsw.gov.au/Global/District-HETI/Westmead_coroners_court_inquest_V
anessa_Anderson.pdf
Mok, Wang, W., Cooper, S., Ang, E. N., & Liaw, S. Y. (2015). Attitudes Towards Vital Signs
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nursing.aspx
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White, J. (2016). How Communication Problems put Patients, hospitals in jeopardy. Healthcare
Business and Technology. Retrieved from
http://www.healthcarebusinesstech.com/communication-patient-harm/
Wood, C. (updated 2015). The importance of Good Record Keeping for nurses. Nursing Times
99 (2), 26. Retrieved from https://www.nursingtimes.net/roles/practice-nurses/the-
importance-of-good-record-keeping-for-nurses/205784.article
12
The Royal AustralianCollege of Medical Administrators (RACMA). (2013). Reviews: The
Garling Report NSW. The Quartely. Retrieved from http://racma.edu.au/index.php?
option=com_content&task=view&id=159&Itemid=336
Stone, P. W., Hughes, R., & Dailey, M. (2008). Creating a Safe and High Quality Health Care
Environment. NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2634/
The University of New Mexico (TUNM). (2016). Importance of Communication in Nursing.
Retrieved from https://rnbsnonline.unm.edu/articles/importance-of-communication-in-
nursing.aspx
Twomey, J. & Cummins, A. (2010). Good Record Keeping. WIN. Retrieved from
http://inmo.ie/tempDocs/WIN%20Record%20Keeping_38,39.pdf
White, J. (2016). How Communication Problems put Patients, hospitals in jeopardy. Healthcare
Business and Technology. Retrieved from
http://www.healthcarebusinesstech.com/communication-patient-harm/
Wood, C. (updated 2015). The importance of Good Record Keeping for nurses. Nursing Times
99 (2), 26. Retrieved from https://www.nursingtimes.net/roles/practice-nurses/the-
importance-of-good-record-keeping-for-nurses/205784.article
VANESSA ANDERSON
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