Clinical Error Cycle: Case Study of Mary Jane Reveals Psych-Out and Unpacking Principle Errors

The essay discusses the case of Mary Jane, a patient who experienced clinical errors during her treatment. The nurses focused solely on her depression, neglecting other potential causes. These errors, known as psych-out and unpacking principle errors, can lead to adverse patient outcomes. To address these errors, awareness programs, clinical audits, and feedback systems should be implemented. The essay concludes with self-reflection on the author's role in the clinical reasoning error and the importance of considering all relevant information in patient care.

Running Head: CLINICAL ERROR CYCLE
Clinical Error Cycle
Name of the Student
Name of the University
Author Note

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Introduction
The essay mainly concentrating on the case study of Mary Jane who is living alone in her
house and her daughters are living in a nearby region although they gave an occasional visit to
her mother. Recently she had a fall, and as a result, her legs were fractured. There was no one to
take her to the hospital. One of her neighbors called her daughter, and then they came. She was a
patient of depression and hypertension as well. After the admission of in the hospital, she was
operated for her fracture and after that nurses observed that she had drastically low blood
pressure. However, the history of depression was not revealed to the nurses by the daughters of
Mary Jane. After knowing this, the nurses were very angry. Although Mary Jane stopped her
medications for depression were stopped by herself. Nurses also complained about the fact that
Mary was not taking her food properly. Along with this, she had symptoms of pale skin, breathe
shortness, low hemoglobin count that is post-operative anemia (Munoz et al. 2015). After the
operation, her daughters had not come for many days and Mary Jane became restless. Nurses
reported that, she did not even want to take medicines along with her foods. She tried to escape
from the hospital twice in the last week and it was reported to the doctors by the nurses. She was
suggested to visit the mental health practitioner for her depression. However, she had not stopped
her medication for hypertension and she was taking beta blockers for her hypertension
(Larochelle, Tobe and Lacourcière 2014). Nurses suspected that, the pale skin, aggressive
nature, restlessness, increased heart rate, lack of interest in taking food is due to the depression
(Joiner, Brown and Kistner 2014). However, it may not be true that, all the symptoms may be
due to her depression. This type of clinical error is referred to as psych-out error (POE) (Clark,
Derakhshan and Desai 2018). According to Dhar and Barton (2016), it is observed that, the

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higher heart rate or tachycardia is directly related to depression. Moreover, depressive disorders
may also create coronary heart diseases as well ( Carney and Freeland 2017).
Clinical Errors
During the assessment of Mary's current problems, the nurses only focused on the
psychotic problems that Mary was experiencing right now. They even did not consider the all
other possible causes of Mary's current situation. This type of error is called unpacking principle
error that is the failure of collecting all the information and that may cause an error in the
treatment and assessment of the patient as well (Rylander and Guerrasio 2016).
Psych-out errors
Psych-out errors refer to the wrong assessment of the patients' condition and it is assumed
that psychotic problems are behind the problems of the patient and it may cause the wrong
treatment of the patients. Various studies showed that, the psych-out errors are quite common in
the clinical settings and along with this it was also noted that such clinical errors were
underreported and unrecognized in the health care setting (Barker and Pistrang 2015). It is
observed that, the patients with psychotic problems are vulnerable to clinical errors in the health
care setting. The study showed that, diagnostic error rates were almost 10-20% of total hospital
setting cases. As most of the cases were not reported as a clinical error, it was observed that 10%
of doctors did not admit their error (Bordini, Stephany and Kliegman 2017). They even did not
take suggestions from their colleagues although those suggestions were quite relevant. The case
of clinical errors was mainly due to several mistakes of the health caregiver and such problems
might be that the doctors or the nurses were in a hurry during collecting the information and
listening to the patient. In some cases it was also observed that sometimes patients had too many

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problems at a time and it confused the nurses or the doctors (Bordini, Stephany and Kliegman
2017). The study of Zun (2016), it was observed that, patients with psychotic disorders are
neglected by the nurses and other doctors as well. However, it was evident that, the psych-out
errors can be lowered by using awareness program. Moreover, the less number of psych-out
errors in the health care settings can also reduce the treatment errors by the nurses and doctors in
the health care setting (Ziv-Beiman and Shahar 2016)
Unpacking principle error (UPE)
Unpacking errors refers to the failure of collecting all the relevant information, that is
unpacking, in establishing a relationship between the condition and the symptoms. In the case of
Mary, it was observed that in the post-operative condition of Mary, the nurses only focused on
the psychotic problems of Mary that is depression. However, they failed to collect information
about the post-operative condition of Mary. It was quite possible that after the operation, Mary
has other physiological complications and due to those complications she was facing such
problems. It is quite possible that the nurses may miss the information and that might be very
crucial for the treatment of the patient (Coxon and Rees 2015). In this case study of Mary, it was
found that the nurses had failed to collect all the information regarding patient’s health and they
focused on the depression related problem of Mary. In addition, the nurses although forgot to
prescribe the cessation of beta blocker that was consumed by Mary due to her hypertension
problem. This negligence in the care of Mary also created a massive problem for Mary. She was
suffering from hypotension. This may happen due to the post-operative situation but the role of
continuous consumption of beta blocker in reducing the blood pressure cannot be nullified
(Jørgensen et al. 2015). In various studies it was observed that, the UPE is one of the significant

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diagnostic errors and it is associated with faulty clinical reasoning, misinterpretation of
investigations of the symptomatic cases (Coxon and Rees 2015).
Reducing the Clinical Error
In order to reduce the clinical errors in the health care setting awareness program can be
launched so that the health care personnel can have knowledge about the adverse effect of
clinical reasoning errors. In addition, clinical audits, mortality and morbidity reviews should be
done. The feedbacks are significant as it can help the clinicians in their self-evaluation process.
The experienced person in the health care setting may give lectures on various experiences of
clinical error cases and it may help the new and doctors and nurses during their work as well
(Wittich et al. 2014).
How could they have been addressed?
The study of Li et al. (2016) also showed that, insomnia or sleeping disturbances might
happen due to the depression. In the case of Mary, it was observed that she had problems in her
sleeping patterns. Sedatives can be given to resolve this problem of insomnia but no medications
were prescribed. The stoppage of beta blocker could have been done to manage the problem
(Jørgensen et al. 2015).
Impact on the Patient Outcome

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Due to the psych-out errors, the actual treatment process can be hampered and that can
create adverse situation to the patient. However, due to such errors, there may be case of
mortality and morbidity (Cooper and Frain 2016).
Self-evaluation and Conclusion
In this case of Mary Jane I, as a member of the nursing team of the hospital setting cannot
deny my role in the incident of the clinical reasoning error. As a part of this case, I failed to
collect all the information from Mary's daughter and from Mary in later situations of the
treatment procedure. I was unable to unpack all the information related to Mary. Firstly, I did not
even think about the depression of Mary although I knew that Mary lived in her house alone
(Ahmad, Altaf and Jan 2016). It was a big mistake for our team. It is essential to assess the
psychological background of the patient as she was living alone and loneliness may contribute to
the onset of depression (Özdemir, Kuzucu and Ak 2014). Although, when we came to know
about the problem of depression of Mary, we referred Mary to the mental health department of
our hospital although Mary had an orthopedic surgery in our department. We completely missed
the fact that Mary might have those symptoms due to her surgery. I assumed that due to her
severe depression, Mary had not proper sleep and food intake as well. I missed the fact that, she
might have such symptoms due to the post-operative condition (Tobin et al. 2014). I also forgot
to prohibit Mary to take a beta blocker and these medicines were used by Mary for the problem
of hypertension. However, after realizing our clinical errors we readily took action to treat
Mary’s problem. We concluded that Mary was experiencing those problems due to the post-
operative situations and her hypotension was observed due to her operational blood loss as post-
operative blood loss is a significant cause of hypotension (Tobin et al. 2014). As Mary had
symptoms of pale skin, weight loss, lack of interest in food intake, we thought that it was due to

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her depression. However, we rectified our errors soon and understood that Mary had pale skin
due to the post-operative anemia. We took relevant actions to manage the conditions of Mary.

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