The Communiqués Podcasts

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 Contents01:10 Editorial03:51 Case #1 I am fine14:34 Case #2 An old drug and a known complication21:41 Reflections of senior nurses24:04 Commentary: Views of a Diabetes Educator32:31 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 Contents01:22 Editorial05:15 Case A fatal downhill slope15:11 Commentary: Falls of wheelchair users: what do we know?19:18 Commentary: Call an OT26:00 Commentary: Looking deeper27:49 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 Contents01:48 Editorial by Associate Professor Nicola Cunningham06:15 Case #1: A fatal toothache by Suzanne Doherty19:54 Case #2: Pulling teeth and tubes - a cautionary tale by Dr Jack D'Arcy36:28 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 Contents01:33 Editorial04:05 Case Cold, wet, in the dark, and alone18:42 Commentary: Preventing unexplained absences25:55 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 Contents01:07 Editorial by Associate Professor Nicola Cunningham07:46 Guest Editorial by Ms Belinda Gibb18:33 Case #1: A culture of care by Dr Glenn Harrison28:42 Case #2: Seen but not heard by Dr Jordana Stanford40:11 Expert Commentary by Dr Olli Wynyard Gonfond: Developing cultural safety behaviours and capabilities in health care46:41 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 Contents01:05 Guest Editorial by Dr Tony Pham04:22 Editorial by Dr Brendan Morrissey07:38 Case: An obstruction in an unfamiliar place by Dr Tony Pham20:07 Expert Commentary #1: Technological solutions: A remedy for human error? By Ms Nicole Mair26:17 Expert Commentary #2: Ready, Set, Go: safe orientation of locum doctors by Dr Brendan Morrissey32:41 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 Contents01:53 Editorial04:47 Case #1 Unknown, unknowable and cannot be known17:07 Case #2 We did our best: revisited19:35 Commentary #1: Impact of dementia on eating24:33 Commentary #2: Resuscitation: lessons involving persons with dementia, guardianship and choking32:21 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 Contents01:08 Editorial06:00 Case #1 Four tales13:32 Brainstorming about the case: views from our nursing colleagues (Case #1)16:05 Commentary #1: A literal approach—recall bias20:06 Commentary #2: Contemplating care—quality improvement rounds23:51 Case #2 Falling off the chair30:06 Brainstorming about the case: views from our nursing colleagues (Case #2)31:48 Commentary #3: See an aside—cognitive testing35:09 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 Contents01:32 Editorial by Associate Professor Nicola Cunningham05:18 Case #1: An alarming error18:37 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 Contents00:00 Guest Editorial by Dr Tiffany Tie 05:08 Editorial by Dr Brendan Morrissey08:58 Case #1: Lost in translation by Dr Tiffany Tie21:42 Expert Commentary #1: Fluid & electrolyte management by Associate Professor Bruce Lister28:02 Expert Commentary #2: Handover by Associate Professor Bruce Lister30:24 Expert Commentary #3: Escalating care in the deteriorating patient by Dr Resy Van Beek36:17 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 ContentsPart 301:38 Expert Commentary by Professor Ian Freckelton: Death investigations and COVID-1910:56 Expert Commentary by Mr Martin Fletcher and Mr Paul Shinkfield: Patient safety and the role of regulators – current and future challenges18:46 Expert Commentary by Professor Michael Dooley: Twenty-year anniversaries: The Clinical Communiqué and Australia’s National Strategy Quality Use of Medicine25:20 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 ContentsPart 201:42 Expert Commentary by Emeritus Professor Ron Paterson: Learning from inquiries and experience10:23 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 ContentsPart 101:43 An anthology of patient safety expert commentaries by Associate Professor Nicola Cunningham06:50 Editorial by Associate Professor Nicola Cunningham23:06 Expert Commentary by Dr Annie Moulden: Come so far but still so far to go28:15 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.Time00:00 Introduction Guest Editors Jacqueline Lim and Gweneth Ng01:00 Case report of coronial inquest into the death of a 65-year-old man04:00 Reflections on case with Dr Danielle Panaccio08:00 Impact of COVID pandemic on clinical work10:00 Tips for medical students to practice now12:15 Views of junior doctors on work culture and managing uncertainty14:05 Wrap-upCreditsWriter, narrator, producer and director: Jacqueline Lim and Gweneth NgGuest interviewee: Dr Danielle PanaccioEditor: Mia GvozdicProducer: Dr Erica MusgroveExecutive 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.Time00:00 Introduction Guest Editor Dalyia Abu-Ghazaleh01:12 Case report05:00 What is a medical protocol? Vox pop06:05 Purpose of medical protocols07:15 Origins of protocols: aviation industry08:20 Protocols are not an absolute09:30 Better use and questioning of protocols10:26 ClosingCreditsWriter, narrator, producer, and director: Dalyia Abu-GhazalehEditor: Mia GvozdicProducer: Dr Erica MusgroveExecutive 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 Content01:31 Editorial: Professor Joseph Ibrahim05:03 Case #1 Get me out by Dar Ray Ooi16:40 Commentary #1: Advance Care Planning by Barbara Hayes26:20 Commentary #2: Improving outcomes for residents by Anita Westera31:05 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 Content01:15 Editorial by Brendan Morrissey05:09 Case #1 Asplenia—think sepsis by Dr David Brough18:16 Expert Commentary #1: Overwhelming Post-Splenectomy Infection – Tips and Traps for Junior Doctors by Associate Professor Merrole Cole-Sinclair27:39 Expert Commentary: An Approach to the Asplenic Patient by Professor Clare Nourse31:54 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 Contents02:20 Editorial by Dr Nicola Cunningham06:54 Case # 1: Don’t fall for it: Fall injuries in the older person are serious15:09 Case # 2: Tunnel vision strikes again21:04 More on the Matter: From up high or down low25:06 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 Content01:09 Editorial: Professor Joseph Ibrahim03:34 Case #1 Is this preventable?08:03 Case #2 The last fall11:52 Commentary #1: Tips to reduce risk of falls by Professor Jacqueline Close18:52 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 Content00:00 Commentary #1: Views from the inside04:44 Commentary #2: Views from the outside09:24 Commentary #3: Teams over five decades14:20 Expert Commentary #2: Junior medical staff and patient safety17:58 Comments from our peers