Impact of Adverse Event on Healthcare Professionals: A Case Study

This case study discusses the impact of adverse events on healthcare professionals, using a scenario of a child's death due to medication error. It explores the short and long term impacts on the nurse involved, the responsibility of unit managers and senior clinicians, impact on team dynamics, communication, trust and perceived competence, and the need for clinical supervision and second victim support.

1Renji Roshin (c3309102)
Clinical scenario description
In this assignment, the clinical scenario that I will be discussing about my personal
experience will be of a 3 year old child having massive abdominal tumour and his care process.
At first, the parents were hesitating to admit the patient at hospital and let him undergo harsh
medical treatment. However, later they decided to allow the healthcare professionals to start
treatment for their child. I was a part of the nursing team that cared for the child in intensive care
unit. Within few days of care we all were attached to the child and his parent seemed relieved
watching their child’s improved health condition. Eventually the child faced several rounds of
rigorous chemotherapy and endured numerous surgeries. We were 6 registered nurses involved
in the care process, however one of the nurse in our team was attached to the child and always
used to take care related initiatives for the child. After 4 months of rigorous medical treatment
the doctors declared the child cancer free and I saw the relief on the parents face after they heard
the news. However, the doctors recommended that the patient should undergo the last step of
chemotherapy prior to discharge that the parent agreed due to the commendable effort of the
healthcare facility to save their child. On the day of chemotherapy, the doctors asked us to
prepare the intravenous bag of sodium chloride and the nurse, who was attached to the child took
the responsibility of this work. However, while preparing for the intravenous bag, the nurse
abruptly filled the intravenous bag with more than 20 times of the recommended dose of sodium
chloride that make the child admitted to the ICU section and after being on the life support for 3
hours, the child died.
Clinical scenario timeline: (In the year 2017)
January February March April May June July August

2Renji Roshin (c3309102)
Identificat
ion of
abdominal
tumour
Approval
for
treatment
Medicatio
n process
Death of
the child
Legal
obligations
taken on
the nurse
Judgment
taken in
this case
Short term and long term impact of clinical situation
In a literature review regarding the effect of patients death on healthcare staff it was
determined that due to the level of attachment and care involved in a nursing profession, they are
the most affected nursing profession after the death of their patient (Kable, Kelly & Adams,
2018). In this clinical scenario also, the nurse, who was attached to the child, faced trauma as the
entire healthcare department blamed her for the death of the patient. The healthcare facility
carried out an investigation regarding the incident however, she was not allowed to take part in
that as she was suspended on the same day of incidence. These were the short term impact of the
incident as she was blamed, isolated and suspended from her duties without any clarification
from her side (Santomauro, Kalkman & Dekker, 2014). She was in shock after the death of the

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children however the investigation did not noticed her care for the patient. The long term impacts
were cancellation of her nursing license that ruined her professional life, made her suffer from
depression and became reason for her suicidal nature (Skourti & Pavlakis, 2017; Stelmaschuk,
2017). After struggling with discrimination, being judged, isolated and blamed for one year, she
committed suicide in her apartment. Therefore, the impact of the patient’s death was the death of
the nurse herself (MacLeod, 2014; Carrillo et al., 2016).
Responsibility of unit managers and senior clinicians
After this adverse event, all the staff involved in the last day of chemotherapy were asked
to provide their statement related to the incident inform of the senior clinicians and unit
managers. However, while discussing about the nurse involved, who was working in the facility
for 4 long years did not mentioned about her strengths and the devotion she used to invest in care
process of each patient (Scott, Hirschinger & Cox, 2008). The unit managers and senior
clinicians who worked with that nurse previously in several case should supported the nurse,
instead of suspending her and should have included her in the care process. As McCay and Wu
(2012) mentions that it is important for the employees to support each other in adverse situations
otherwise the effect of an adverse situation can affect one of them drastically to the extent of
suicidal behaviors, which could be observed in this case (Panella et al., 2015). Further the
managers and senior staff should be supportive and reliable so that the staff involved in the
situation can describe the event honestly to them without having any fear. However, in this case,
the senior staff not only ask any clarification from the nurse, but also suspended her from the
facility making her suffer from depression (Mira et al., 2015).

4Renji Roshin (c3309102)
Impact of adverse event on team dynamics, communication, trust and perceived
competence
Healthcare facility is a process that involved numerous amount of interfaces and handoffs
that seeks a collaboration and combination of employees with various level of occupational and
educational level (Burlison et al., 2016). Sirriyeh et al. (2010) also mentions that in a healthcare
facility, a patient faces more than 50 employee everyday as care is a process of combination.
Therefore, starting from happiness to stressful situations, they should stick together so that no
adverse situation can affect their mental peace. However, in this clinical scenario, the adverse
event affected the team unity and spirit that changed the team dynamics, trust and compatibility
among the nursing staff (Sirriyeh et al., 2010). Instead of defending the nurse accused for the
event, other nursing professionals also started isolating her from their group that affected the
mental health of the nurse leading to depression and suicidal tendency (Burlison et al., 2016).
Internal and external reporting and/or investigations required
It should be determined that reporting procedure is important for healthcare facilities to
maintain their care service quality and accountability depending on which, the revenue of the
care facility increases or decreases (Van Gerven et al., 2014). There are two type of reporting
system such as direct reporting which is done by the care facility and indirect reporting or
concerns and complaints which is done by the first victims of the event or the families. In this
case, the Australian healthcare rules determine that the healthcare facilities should bear facilities
using which they can carry out internal reporting and investigation which is unbiased, notifiable
and honest. Further the legislations also determine that clinical governance of the healthcare
should be transparent, accountable, and fair and should give priority to the adverse event
reporting and investigation (Skourti & Pavlakis, 2017). Moreover, the reporting process is

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consisting of requirements, complying which can provide the healthcare organization to lead the
investigation process. External investigation can also involve the healthcare facility investigation
team as joint investigation process. As well as, if the healthcare facility allows, the professionals
involved or accused of adverse event can also take part in the investigation process. As per the
data of Scott et al. (2009) and Scott, Hirschinger and Cox (2008) the serious incident reporting
requirements are the permission of Patient Safety Surveillance Unit or PSSU, primary
investigation report conducted by the healthcare facility and especially the Risk management and
Safety Quality and Performance team (Ullström et al., 2014; Mira et al., 2015). Further, the
external investigation is dependent on the verdict of the healthcare department authorities as
depending on the reliability, honesty and trustworthiness of the report of the internal reporting,
the commencement of external reporting depends (Wu, 2000).
Need for clinical supervision following an adverse event
Medication error is one of the most important errors in healthcare profession that are
causing millions of death worldwide nowadays. Increased responsibility, strict working hours
and tireless efforts are the reasons due to which nursing professionals face burn outs that affect
their reasoning ability (Seys et al., 2013; Jones & Treiber, 2012). In such situation they commit
mistakes that are harmful for their patients as well as their profession (Chu, 2018). However, at
this time point they need tremendous collegiate and institutional support to overcome the guilt of
their fault. The healthcare organizations should provide them a chance to describe their point of
view about the incident and should seek their clarification (Denham, 2007; Harrison wet al.,
2015). Further they should be allowed to take part in the investigation process so that they can
also understand the mistake they did in the care process (Kim et al., 2017). Further, the
healthcare professionals involved in such event should be provided with clinical supervision so

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that someone can assist them in their care process (Van Gerven et al., 2014; Burlison et al.,
2016).
Second victim in prevention of adverse event
The second victims can also take part in the prevention of such events by sharing their
experience of such events to the future healthcare professionals or nurses. This will help them
future nurses to learn from the mistakes of the second victim and they will be determined to help
the patients with complete concentration (Skourti & Pavlakis, 2017). Further, the second victim
can also take part in the identification and investigation process that will help her to regain her
confidence and find the reason for the death of her patient, increasing her self-esteem (Treiber &
Jones, 2010).

7Renji Roshin (c3309102)
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