The aim of this study is to analyze a personal experience (Using the Fishbone Model) of an incident caused due to failure in the delivery of appropriate and safe care for a patient resulting in an accident (Luo et al., 2018). The case study would be analyzed following the London Protocol and outline the information related to the experience and event according to what happened, individuals who were involved, when the incident occurred, severity of the potential or actual harm, possibility of recurrence and the consequences of the event (Lamba et al., 2014). The risk factors are then analyzed using the Fishbone model to identify how the safety and quality of care can be improved under clinical governance frameworks (Currie et al., 2017).
The incident took place when I was working as a trainee in the emergency department, when an elderly male patient (Ethnicity: Aboriginal), aged 80 years old (Mr X) presented with a case of accidental injury due to a fall and resulted in a broken radial bone on the right hand. The patient was suffering from Dementia, and is mobility and gait was affected due to his condition. Mr X was given a rolling walker to aid his balance and gait, however, he forgot to take the walker with him while going to the toilet, slipped and fell. He broke his right radial bone while trying to break his fall and it hit the basin. Mr X was in a lot of pain when he arrived and was promptly given sedatives. After talking to the family of Mr X (his wife and daughter), it was found that the walker was given to him a month ago, after he fell while getting out of the bed and hurt his head and that a risk assessment of the patient’s house was not performed to identify and address the fall hazards. Further assessment of the patient revealed that his motor reflexes are poor leading to improper hand to eye coordination, which increased his risks of falling. The incident occurred in the morning that day, when the patient was conducting his activities of daily living. The fall occurred because the patient was unable to balance himself and the floor of the toilet was slippery. With the type of fall the patient took, it could be understood that under the given conditions, the fall could have had serious and even fatal consequences. Moreover, due to his condition and the patient is still at high risks of falling with the possibility of even more serious outcomes. This shows a failure of the healthcare organization in the providence of safe and quality care for the patient in the previous health encounter (Taylor et al., 2017).
The importance of the participation of the consumer (or patients and their families) in the planning and implementation of a safe and quality care has been implemented by the Australian Comission on Safety and Quality in Healthcare (Standard 2) and the principle of patient centered care followed by healthcare organizations in Australia (Australian Commission on Safety and Quality in Health Care, 2012). This framework supports the importance of the views, opinions and preferences of the patient and their families in the care delivery strategy and develops a care. Involving patients and their families in the care planning and also helps to improve communication and better sharing of information. In the given scenario, the nurses and healthcare professionals from the previous health incident did not assess the preferences of the patient or their family and also failed to inform the family of the best practices to care for the patient or did not share important information such as strategies to improve gait and balance and support memory. This also shows a failure to develop a therapeutic relation with the patient. This significantly increased the risks of a recurrence of fall related injury leading up to the recent admission that I witnessed. Thus it was necessary to involve the patient and his family to ensure the health and wellbeing of the patient (Sarrami?Foroushani et al., 2015).
A lack of clinical effectiveness was caused because of the failure of the previous healthcare professionals who was involved in the previous health encounter to perform a thorough assessment of the patient’s home for any fall related hazards to identify any risks and mitigate them accordingly. The healthcare professionals also overlooked the necessity to educate the patient and their families on strategies to improve the balance and gait of the patient, educate him on strategies to improve memory and assess the condition of the patient for any conditions that needs to be promptly addressed (Usher et al., 2018). The patient had weak motor coordination which was not identified before, and the patient or his family were unaware of exercise routines that could help the patient to improve his balance and gait. Also strategies to improve or aid the memory (such as alarms, notes or labels) of the patient was not implemented or used. Such aspects have been highlighted and implied under the Standard 10 of NSQHS Standards and were evidently followed by the healthcare professionals in the previous encounter (ACSQHC, 2012). Due to such overlook, the clinical effectiveness of the care provided to the patient was inadequate to prevent the risk of fall related injury (Bamelis et al., 2014).
Effective workforce is also vital to ensure the best outcome of a medical intervention. Using a multidisciplinary healthcare team can ensure that all the different facets that are related to the health of the patient and the safety and quality of care are analyzed and the care plan is based using these inputs (Mumford et al., 2016). The clinical failure to provide proper care for the patient could also be attributed to the ineffectiveness of the healthcare workforce involved in the previous incident (Jones & Killion, 2017). Because of the ineffectiveness of the workforce and the failure to use a multidisciplinary healthcare team, activities such as risk assessment, patient and family education, neuromuscular assessments as well as social support and nursing support strategies were not offered for the patient to help him to manage the long term condition of dementia. Also, there was a significant communication barrier between the patient and the healthcare profession since the patient was Aboriginal and did not understand English properly. This also is a failure on the part of the healthcare team as they were unable to use effective communication strategies to ensure patient understand them or to understand the concerns of the patient and thus was not in accordance to the Standard 1 of (Flanigan, 2016).
Management of risks is one of the most significant considerations in the given context, since the patient had a high risk of falling and fall related injuries due to the following satiations/conditions: his diagnosis of dementia, poor motor coordination, previous incident of fall, memory problems as well as his advanced age. Effective risk management starts with a comprehensive risk assessment to identify hazards to fall related incidents. The environmental hazards such as slippery floor, inadequate lighting, and arrangement of the furniture as well as physiological conditions were not properly assessed to identify the risks of falling and injuries. Effective management also involved developing plans to prevent future incidents through precautions and having strategies to address any adverse events (such as exercise routines, implementing fixtures that can aid the patients balance and gait), which was overlooked by the health care professionals (Azami-Aghdash et al., 2015).
Conclusion:
Through the analysis of the incident that I personally witnessed, using the fishbone model, I was able to understand the factors that caused the accident of the patient thereby injuring him. It was evident that the healthcare professionals in the previous encounter failed to adequately identify the risks and hazards of fall for the patient or educate the patient of his family on strategies to prevent them in the future, which led to the most recent admission due to radial bone fracture. It is vital therefore that the clinical governance framework be utilized to ensure quality and care for the patient through the implementation of strategies such as consumer participation, clinical effectiveness, effective workforce and risk management.
References:
Australian Commission on Safety and Quality in Health Care. (2012). National safety and quality health service standards. Australian Commission on Safety and Quality in Health Care.Retrieved from: https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf
Azami-Aghdash, S., Tabrizi, J. S., Sadeghi-Bazargani, H., Hajebrahimi, S., & Naghavi-Behzad, M. (2015). Developing performance indicators for clinical governance in dimensions of risk management and clinical effectiveness. International Journal for Quality in Health Care, 27(2), 110-116. DOI: https://doi.org/10.1093/intqhc/mzu102
Bamelis, L. L., Evers, S. M., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171(3), 305-322. DOI: https://doi.org/10.1176/appi.ajp.2013.12040518
Currie, J., Mateer, J., Weston, D., Anderson, E., & Harding, J. (2017). Implementation of a clinical governance framework to 17 combat service support brigade, Australian army. International Journal of Health Governance, 22(1), 15-24. DOI: https://doi.org/10.1108/IJHG-04-2016-0024
Flanigan, K. (2016). NSQHS standard-patient identification. ACORN: The Journal of Perioperative Nursing in Australia, 29(1), 23. Retieved from: https://search.informit.com.au/documentSummary;dn=883877754554045;res=IELHEA
Jones, A., & Killion, S. (2017). title Clinical governance for Primary Health Networks. Retrieved from: https://ahha.asn.au/system/files/docs/publications/210417_issues_brief_no_22-_clinical_governance_for_phns.pdf
Lamba, A. R., Linn, K., & Fletcher, K. E. (2014). Identifying patient safety problems during team rounds: an ethnographic study. BMJ Qual Saf, bmjqs-2013. DOI: https://dx.doi.org/10.1136/bmjqs-2013-002324
Luo, T., Wu, C., & Duan, L. (2018). Fishbone diagram and risk matrix analysis method and its application in safety assessment of natural gas spherical tank. Journal of Cleaner Production, 174, 296-304. DOI: https://doi.org/10.1016/j.jclepro.2017.10.334
Mumford, K., Young, A. C., & Nawaz, S. (2016). Federal public health workforce development: an evidence-based approach for defining competencies. Journal of public health management and practice: JPHMP, 22(3), 290. DOI: 10.1097/PHH.0000000000000205
Sarrami?Foroushani, P., Travaglia, J., Debono, D., Clay?Williams, R., & Braithwaite, J. (2015). Scoping meta?review: introducing a new methodology. Clinical and translational science, 8(1), 77-81. DOI: https://doi.org/10.1111/cts.12188
Taylor, M. E., Lord, S. R., Brodaty, H., Kurrle, S. E., Hamilton, S., Ramsay, E., … & Close, J. C. (2017). A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia. International psychogeriatrics, 29(1), 81-91. DOI: https://doi.org/10.1017/S1041610216001629
Usher, K., Woods, C., Conway, J., Lea, J., Parker, V., Barrett, F., … & Jackson, D. (2018). Patient safety content and delivery in pre-registration nursing curricula: A national cross-sectional survey study. Nurse education today, 66, 82-89. DOI: https://doi.org/10.1016/j.nedt.2018.04.013
Essay Writing Service Features
Our Experience
No matter how complex your assignment is, we can find the right professional for your specific task. Contact Essay is an essay writing company that hires only the smartest minds to help you with your projects. Our expertise allows us to provide students with high-quality academic writing, editing & proofreading services.
Free Features
Free revision policy
$10Free bibliography & reference
$8Free title page
$8Free formatting
$8How Our Essay Writing Service Works
First, you will need to complete an order form. It's not difficult but, in case there is anything you find not to be clear, you may always call us so that we can guide you through it. On the order form, you will need to include some basic information concerning your order: subject, topic, number of pages, etc. We also encourage our clients to upload any relevant information or sources that will help.
Complete the order form
Once we have all the information and instructions that we need, we select the most suitable writer for your assignment. While everything seems to be clear, the writer, who has complete knowledge of the subject, may need clarification from you. It is at that point that you would receive a call or email from us.
Writer’s assignment
As soon as the writer has finished, it will be delivered both to the website and to your email address so that you will not miss it. If your deadline is close at hand, we will place a call to you to make sure that you receive the paper on time.
Completing the order and download