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Adverse outcome for the patient

Identify a case from the NSW Nurses and Midwives’ Board or AHPRA, HCC or Caselaw website which involved a registered nurse(s) who had their registration cancelled or suspended for greater than 6 months due to their involvement in an adverse event for a patient in their care..

NB: provide the reference and link to the case

THEN

1. What actions/omissions on the part of the Registered Nurse(s) contributed to the adverse outcome for the patient.

2. Were there any other factors (e.g. systems-based) that contributed to the adverse outcome for this patient?

3. With reference to the evidence based literature (including relevant NSW policies) outline the actions that should have been taken by the Registered Nurse(s) to prevent adverse outcome for this patient.