Clinical Incidents in Nursing Assignment

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Any failure in health care system is a critical issue that leads to many public inquiries.
One such famous public inquiry is the Bundaberg public inquiry which investigated about the
events of clinical incidents, surgical errors and multiple adequacies at Bundaberg hospital.
This incident is a famous example of Australian health system failure. This papers aims to
review the Bundaberg hospital failure based on the module content related to clinical
governance and organizational culture.
Clinical governance part:
The revised clinical governance framework consists of five domains such as leadership
and culture, workforce, risk management, clinical practice and consumer partnership. The
system failure in the Bundaberg hospital might have been influenced by the domain of
leadership and culture and risk management. The Bundaberg hospital system failure has been
linked to leadership and culture because the hospital was found to have a faulty safety culture
resulting in many surgical errors and adverse events for patient (Davies, 2005).
For example, as per the explanation of Dr. Thiele in the Bundaberg inquiry, he reported
being frustrated with the culture at the hospital as there were decline in safety standards,
inefficiency in surgical scheduling and loss of registrars. The hospital culture focused on
economic rationalism rather than patient care and safety (Davies, 2005). Organizational
culture is informed by nature of its leadership (Muls et al., 2015) and in the context of
Bundaberg inquiry, poor safety culture was seen because of lack of appropriate leadership
and culture to support high standard and quality of care at Bundaberg hospital. The
leadership of the hospital was not active enough to address safety issues and encourage
reporting about adverse events too. Joint Commission (2017) explains that in any health care

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organization, the first priority of all leaders should be to be accountable for effective care and
adapt all measures to promote safety of patients. This involves playing active role to improve
safety and organizational culture and address systematic flaws in the organization. However,
leadership role was completely missing in the Bundaberg hospital. Terzioglu, Temel and
Uslu Sahan (2016) also recommend having robust institutional culture to promote justice
both for patients as well as staffs.
In any hospital, risk management is crucial to minimize harm that can occur due to faulty
clinical systems or practices in a hospital. It involves the systematic identification,
assessment and evaluation of risk. However, the Bundaberg clinical system failure occurred
as it had poor system to manage risk or any system to report about surgical errors or patient
safety risk. The hospital was instead accused for inappropriate reporting of deaths and there
were many cases of incomplete incident report. Hence, if the hospital has adequate risk
management plan, they would have documented any patient safety event in incident report
and dealt with it through formal channels (Davies, 2005). However, any such activity was
seriously missing at the hospital. Rafter et al. (2014) explains adverse event can occur in any
setting. However, the crucial thing is that the organizational leadership must focus on
learning from those adverse events and not repeating them. Unless there is systematic method
to identify and evaluate adverse events, progress in patient safety cannot occur. The same
case was found for the Bundaberg hospital failure case too. Hence, to ensure that such errors
do occur again, it is necessary that clinical managers in the hospital establish a system for
risk management and controlling adverse events. Howell et al. (2017) recommends that
incident reporting system in hospitals should be introduced as it not only helps in the