Reflect on your past experiences as a medical professional.
Compare your experiences in a workplace (or previously) with current literature regarding health service design.
You should concentrate your reflections on:
How the principles and practices of clinical governance can be used to improve healthcare systems
Your role as an individual employee in ensuring that healthcare is safe and quality
How can consumers be empowered to take an active part in their healthcare experience
Answer to Question: SNPG927 Promoting Clinical Excellence
It is crucial to adhere to certain principles and protocols to ensure that healthcare recipients get the best possible service.
The key to ensuring patient recovery and well-being is maintaining quality and safety in healthcare.
For greater understanding of the topic of safety and quality in healthcare, a case study may be cited from relevant literature.
Gluyas & Morrison (2014) described the incident in which a nursing home resident died. They also included the evidence of medication errors that preceded the event.
The article provides a glimpse into cognitive function, which is related to thoughts and information processing capability of the subject.
The resident’s death was due to the underlying cause of the disease, and not any personal involvement.
Surprisingly, the attending nurse, who was caring for the resident, was responsible in a medication error that occurred a few hours prior to the resident’s passing. Subcutaneously, 25mg rather than 2.5mg of Morphine was administered.
A definite framework is essential for the analysis of care and contextual factors that affect patient safety in the clinical sector.
The London Protocol was developed to make it easier for patients to be identified and treated in a proper manner. 2014).
The London Protocol proposes that certain factors can influence clinical practice, which could lead to the causation or occurrence of an incident.
There are many contributing factors that could be considered. These include: task and technology factors; individual factors; team factors; work environment factors; organizational and management factor factors.
Individual, team, and workplace environmental factors are particularly relevant in this case.
Even though the mistaken dose of subcutaneous administrations of morphine by the nurse may have been the primary cause, the fatal outcome could have been due to the patient factor.
According to some reports, the nurse was a newly graduated nurse. She was performing her duty as registered nurse in the same shift for the second consecutive time.
Despite being reminded by the nursing staff that the prescribed morphine medication was due, it was not in their sight. When the nurse asked her to double-check the medication dosage, she felt that they didn’t see the point.
Workload can lead to a reduction in quality and lower productivity (Van Bogaertetet al. 2014).
Team factor was a contributing factor to the incident.
Uncommon knowledge of morphine administration, as well as the lack of orientation for new staff in nursing homes, along with the heavy workload and need to collaborate extensively and closely with healthcare personnel outside of the organization, contributed to chaos and increased work pressure for the nurses.
This case was caused by the difference between the workload for newly appointed registered nurses and the work environment.
The patient experience of being given the wrong dose of medication, as shown on the second side, could be attributed to multiple factors, including individual, team, and workplace environment.
In today’s healthcare sector, clinical governance is highly sought after. This concept focuses on improving the delivery of healthcare.
Through the removal of unsafe or ineffective practices or those of limited benefit, clinical governance aims to enhance the service’s effectiveness and efficiency.
Participation from the consumer has been acknowledged as an essential element of this process.
The measure was considered to be a progressive step that could allow resource allocation to be sustained and done correctly by taking into consideration consumer preferences and views.
Relevant literatures show that consumer participation is becoming more prominent in publicly funded health services. This has been documented in standards, policies.
The allocation of resources was essentially based on communication, consultation and participation to improve the provision for healthcare service recipients.
Clinical governance is increasingly about incorporating consumer views and perspectives. They are essential to ensuring that vital decision-making abilities are maintained (Harris and al. 2017).
Patients who are considered potential service users can be considered consumers.
It is possible to enhance the quality and safety by involving patients in the process of service delivery. This could be done through understanding and support.
Public health policy has been incorporated to address the issue. This is to help patients receive the best possible healthcare.
Hripcsak et. al. (2009). Health data acquired takes into consideration patient preferences and values so that the healthcare delivery experience can be improved to some degree. 2014).
In this situation, the principle that consumers participated is not true. There is no evidence to show that patients’ preferences or opinions were taken into consideration when designing the care system.
The nursing home resident who died due to medication error was also identified.
It was not possible to determine whether the nurse failed to comply with the patient’s wishes.
Another important aspect of clinical care is clinical effectiveness. This is so that patients in greatest need can receive the best care.
Healthcare professionals and health care providers need to make more efforts to improve clinical care.
Clinical governance is an indicator of a continuous learning atmosphere that focuses on creating safe, responsive, and effective services.
The commissioning of quality healthcare services remains the key to the delivery of healthcare. Evidence-based practices have been used to inform healthcare professionals about the most efficient ways to improve service effectiveness (Hamer 2014; Collinson 2015).
Research has also focused on providing safe, high quality healthcare services using innovative research.
In this context, it is important to have a continuous, integrated and coordinated healthcare delivery (Jones and Killion 2017,).
A simulation-based strategy could have helped improve clinical effectiveness and addressed the issues in the present scenario.
If you invest in simulation-based procedures, knowledge-based and rule-based mistakes can be easily avoided. They are also a key tool to avoid errors such as medication administration (Keerse and al. 2013).
The ability to have a more skilled workforce within the clinical team could lead to better outcomes in terms of providing quality healthcare service for patients.
In order to achieve the best outcomes in clinical settings, modern interdisciplinary strategies are being emphasized.
A multi-professional healthcare framework is essential for the effective management of clinical standards. 2017).
Engagement of the appropriate workforce in the clinical setting is crucial for the facilitation of the learning of evidence-based practice principles.
McKeever and others suggested that clinicians, nurses, as well as inter-professional students, play crucial roles in maintaining an efficient workforce in order to improve the clinical outcomes. 2016).
This led to medication errors.
In this context, it was also difficult to orient new staff members.
The situation might have been prevented if registered nurses and attending nurses had a united front and provided adequate professional knowledge.
Risk management, another aspect of clinical Governance, ensures patients receive the highest level of care and that they do not pose any risks to their health.
It is important to have both governance and management roles in order to properly conduct risk assessments and the subsequent tasks (Brennan, Flynn, 2014).
Training the healthcare staff involved in the provision of healthcare service may help to promote a culture of patient safety. 2015).
The absence of adequate training and orientation to the new registered nurse in order to increase the familiarity with the environment around her might have helped to prevent the risks associated with medication administration.
Promoting clinical excellence involves the interaction of multiple factors like the principles of consumer involvement, clinical effectiveness, workforce efficiency, and risk management. This is what underlies the clinical governance aspect.
These components must be highlighted in order to offer quality healthcare and safety to patients.
Lessons Learnt’s patient safety training programme helps to build a stronger foundation.
BMJ Qual Saf. 23(1).
Brennan N.M. and Flynn M.A.
Differentiating between clinical governance, clinic management and clinical practice.
Clinical Governance: An International Journal. 18(2) pp.114-131.
Gluyas H., and Morrison P. (2014).
Human factors and medication error: A case study.
Nursing Standard 29(15), pp.37–42.
Hamer S. and Collinson G.
Achieving Evidence Based Practice E-Book: A Handbook For Practitioners Elsevier Health Sciences.
Harris, C. Harris. Ko. H. Waller. C. Sloss. P. Williams.
Sustainability in Health Care: Allocating Resources Effectively. 4: Exploring the possibilities and methods for consumer involvement in resource allocation in a healthcare setting.
BMC Health services research, 17(1) p.329.Hripcsak, G., Bloomrosen, M., FlatelyBrennan, P., Chute, C.G., Cimino, J., Detmer, D.E., Edmunds, M., Embi, P.J., Goldstein, M.M., Hammond, W.E.
A report from AMIA’s 2012 Health Policy Meeting.
Journal of the American Medical Informatics Association. 21(2). pp.204-211.
Jones, A. & Killion, S. 2017. Title Clinical Governance for Primary Health Networks.
Keers R.N. Williams S.D. Cooke J. Ashcroft D.M.
Prevalence and nature errors in medication administration in health care settings: A systematic analysis of direct observational evidence.
Annals of Pharmacotherapy. 47(2).
Kennedy, M. Elcock M. Ellis D. Tall G.
Pre-hospital and retrieval medical: Clinical governance models and workforce models. Emergency Medicine Australasia.
McKeever S., Twomey B., Hawley M., Lima S., Kinney S. & Newall F. 2016.
The introduction of a Nursing Clinical Excellence Committee: Engaging a Nursing Staff in Evidence?Based Nursing Practice.
Worldviews on Evidence Based nursing, 13(1), pp. 85-88.
Sendlhofer G. Brunner G. Tax C. Falzberger G. Gmolle J. Leitgeb K. Kober B. Kamolz L.P.
Implementation of clinical risk management systems in large university hospitals: The impact on risk managers. Wiener klinische Wochenschrift, 127(1-2), pp.1-11.Van Bogaert, P., Timmermans, O., Weeks, S.M., van Heusden, D., Wouters, K. and Franck, E., 2014.
What is the impact of nursing unit teams? Nurses’ perceptions of their work environment, how they are structured and what they do, as well as burnout, on job outcomes and quality of care.
International journal nursing studies, 51(8). pp. 1123-1134.