HLSC604 Shareboard activity 5 by Sue Gledhill https://padlet.com/sue_gledhill/bka2t9e552g2 Your thoughts about the events at Djerriwarrh Health Service? en-us 2017-02-10 03:34:30 UTC 2017-05-21 00:10:12 UTC hello@padlet.com By Judith Lancucki https://padlet.com/sue_gledhill/bka2t9e552g2/wish/167980744 This incident is appalling.The main issue here is from top to bottom management.The organisational culture played an important role between leadership behavior and organisational commitment. Employees commitment and satisfaction are influenced by supportive culture from the organisation.This incident is not isolated. Understaffing, lack of training, breakdown in communication etc are barriers for effective delivery of safe and quality patient care.There are a mountain of resources on risk management strategies that will provide every health service organisation with a framework to assess and address the risk identified.But the fundamental aspect of every decision particularly in health care is the application of the "golden rule..."]]> 2017-04-24 22:24:21 UTC https://padlet.com/sue_gledhill/bka2t9e552g2/wish/167980744 By Yana Wu https://padlet.com/sue_gledhill/bka2t9e552g2/wish/170404680 In Djerriwarrh Health Services ‘s case, it shows an inadequate of clinical governance strategies to meet the increased service needs of the community. At Bacchus Marsh 2006-2013, the number of births had experienced a doubling, however; the staffing infrastructure supporting  system had not been updated accordingly. For example, DJHS reviews shown a lack of on-call specialist paediatrics for the maternity service which had a negative impact on emergency management. In my opinion, the hospital failed to meet the requirement of the National Standard 9(Recognising and responding to clinical deterioration in Acute Health Care). Plus, misusing and/or misinterpretation of fatal surveillance by cardiotocography caused perinatal deaths suggests that the workforce is inadequately skilled in fetal surveillance. The lack of high quality staff education plays an important role in poor clinical management and lead to adverse clinical outcomes. Overall, Djerriwarrh Health Service failed to meet the requirement of the National Standard 1 (Governance for safety and quality in health service organization) and National Standard 9 (Recognising and responding to clinical deterioration in acute health care) during the given time period. 

Yana Wu

]]> 2017-05-08 01:16:39 UTC https://padlet.com/sue_gledhill/bka2t9e552g2/wish/170404680 Yes, you are right Yana and right to be appalled, Judith. Hard to believe that the matter persisted for two years before being addressed. Do you think that one of the root causes of the issue could have been Djerriwarrh taking on cases beyond its capacity? If so, why did they do so, do you think when they could have referred the high risk cases on? Sue sue_gledhill https://padlet.com/sue_gledhill/bka2t9e552g2/wish/170968510 2017-05-10 10:32:15 UTC https://padlet.com/sue_gledhill/bka2t9e552g2/wish/170968510 Trish Mair https://padlet.com/sue_gledhill/bka2t9e552g2/wish/171444869 Yes Yana I agree with you after reading all the articles. Failure  to meet standard one in the first place to have governance structures in place to follow at all times to ensure mother and baby safety. Policies and procedures provide safe guidelines for midwives to follow to achieve optimal outcomes
Also staff were not adequately trained in CTG
monitoring which would have alerted staff to increased foetal distress and emergency treatment could have been sought immediately. I now at the RBWH when I was doing my Midwifery training. All at risk births and diabetic mothers automatically were reviewed by doctor;s never by midwives.
Even a 40week normal birth can quickly result in a CAT3 emergency caesarean.I learnt and saw first hand how quickly things can go from normal to emergency to save the baby. Every hospital needs an emergency on call paediatrician, it is so negligent that even this was not in place.
As Yana said standard 9 was also not met]]> 2017-05-12 09:56:54 UTC https://padlet.com/sue_gledhill/bka2t9e552g2/wish/171444869 Katie O'Byrne https://padlet.com/sue_gledhill/bka2t9e552g2/wish/172949120
This shows a big system failure with particular reference to Standard One. It appears that there was not a particular individual at fault, but rather a whole system that failed these women and their children. It is disappointing that action was not taken sooner, however after reading the detailed report that the many changes recommended will create the positive change. I agree with the point Sue has made, that the hospital has taken cases beyond their capacity. This is evidenced by the 34 week case that was transferred to another facility that sparked the issues occurring at Djerriwarrh. It is very scary hearing these stories and I hope that this doesn't occur again at any health facilities. If the hospital's comply with the accreditation standards this should prevent these awful events from occurring.]]> 2017-05-21 00:07:06 UTC https://padlet.com/sue_gledhill/bka2t9e552g2/wish/172949120