Healthcare Safety & Evidence-Based Practice

This assignment delves into critical aspects of healthcare safety and evidence-based practice. It examines the impact of patient safety training programs, analyzes the distinctions between clinical governance, management, and practice, investigates human factors contributing to medication errors, and emphasizes the importance of achieving evidence-based practice through resources like the 'Achieving Evidence-Based Practice' handbook. The assignment also touches on sustainable healthcare resource allocation and the role of nursing workforce engagement in promoting evidence-based care.

Running head: PROMOTING CLINICAL EXCELLENCE
Promoting Clinical Excellence
Name of the Student:
Name of the University:
Author Note:

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Assessment task 2
In today’s healthcare sector, it is imperative to abide by certain protocols and principles
so that the optimal service delivery may be rendered to the healthcare recipients. Maintenance of
quality and safety in healthcare is a crucial step to foster the quicker recovery and wellbeing of
the patient. In this connection for allowing greater insight about the topic pertaining to quality
and or safety of healthcare, a case study as appeared in a relevant literature may be cited. Gluyas
and Morrison (2014) in their work have represented the incidence that described the death of a
nursing home resident in addition to medication error that preceded the death. The article
provided a sneak peek into the issue of cognitive functioning that is related with the thoughts and
processing of information capability for the concerned person. The cause of death for the
resident was attributed with the underlying pathogenesis of the disease rather than any
involvement of any person. However, on closer examinations, it was revealed that the attending
nurse who was in charge of the patient was responsible for a medication error occurring a few
hours before the resident’s death in which 25mg of morphine instead of 2.5mg was
subcutaneously administered.
The utility of applying a definite framework for analysis of the care and contextual
factors in patient safety is of paramount importance in clinical sector. The London Protocol has
been put in place to streamline the recognition of the patient safety issue in a suitable manner
through root cause analysis (Ahmed et al. 2014). According to the propositions made in the
London Protocol, clinical practice that might lead to causation of an incident in turn may be
influence by certain contributing factors. The types of contributing factors might include patient
factors, task and technology factors, individual factors, team factors, work environmental factors,

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organizational and management factors in addition to institutional context factors. Among these
identified factors, individual, team and work environmental factors are of particular relevance in
the give case scenario. The wrong dose of subcutaneous administration of morphine as
performed by nurse may be stated as the individual factor that lead to the incident although the
patient factor due to criticality of the underlying disease have been attributed to the ultimately
cause in death. It has been reported that the nurse was a newly graduate nurse who was
performing her duty as a registered nurse for the second time in that shift along with other three
extended care assistants or nursing assistants. Despite the fact that these nursing assistants
constantly reminded the nurse regarding the administration of the prescribed morphine
medication as long overdue, it felt short of their sight as well when the nurse asked the one who
was with her on duty while administering the medication to check the dosage of medication.
Quality of work seems to be hampered often under the influence of nursing burnout because of
workload (Van Bogaertet al. 2014). Thus, team factor contributed to the causation of the
incident. Further, unfamiliarity with morphine administration, skipping of the orientation course
for the new staff in nursing home beside the excessive workload due to large number of patients
and need to collaborate extensively with other healthcare personnel outside the organization
contributed to chaos and work pressure for the nursing professional. Thus, in this case the work
environmental factor due to tremendous workload as opposed to meant for a newly appointed
registered nurse resulted in causing the incident. Therefore, the patient experience of undergoing
wrong dosage of medication as found on the second place while administering the medication
may be identified to have occurred because of interaction of multiple factors that encompassed
individual, team and work environment.

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Clinical governance is a coveted concept in the modern healthcare sector where emphasis
is laid on optimizing the healthcare delivery system. Enhancement of effectiveness and
efficiency of service is falls under the primary objective of clinical governance through removal
or restricting the unsafe practices or the ones that are of little benefits. Integral to this process,
the participation of consumer has been acknowledged as a crucial factor. The measure has been
considered as a progressive step by which resource allocation may be sustained and done
properly by taking into consideration consumer views and preferences. Relevant literatures have
shown that consumer participation is increasingly gaining prominence in the publicly funded
health services and has been documented in standards and policies. Resource allocation process
essentially catered to communication, consultation and participation for improving the provision
of health service for the healthcare service recipients. Consumer values and perspectives are
increasingly gaining prominence in the clinical governance sector to be included while
undertaking vital decision-making ability (Harris et al. 2017). Patients who are considered as the
potential service users are considered as the consumers. Therefore, understanding and support
received from the patient might be indicative of enhancing the quality and safety of the service
that is being delivered to them. The issue has been raised and incorporated in public health
policy in an aim to foster the provision of most suitable healthcare service to the patient. Health
data that has been procured takes into account the values and preferences of the patient so that
the healthcare service delivery experience may be bettered to some extent (Hripcsak et al. 2014).
In the given context, the principle of consumer participation do not hold true as there is no
documented evidence whether the opinions and preferences of the patient was taken into
consideration while framing the care regime. Moreover, medication error was the identified issue
that might possibly have been a factor leading to death of the nursing home resident. Negligence

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of duty for nurses by not conforming to the preferences of the patient has not been stated in the
case study so that we may infer that consumer participation was overlooked.
Clinical effectiveness is another vital component that is stressed upon in clinical setting
so that optimal care service may be rendered to the patients in need. The healthcare practitioners
and professionals must increasingly make efforts so that the efficacy of clinical care may be
enhanced significantly. Clinical governance being indicative of a continuous learning
environment focuses essentially on creation of safe, responsive and effective services.
Commissioning of quality of care services remains at the pivot of the healthcare delivery system
whereby evidence based practice has been emphasized to inform the healthcare personnel
regarding the following of the most prudent methods to increase the efficacy of service (Hamer
and Collinson 2014). Other relevant research has also laid emphasis on rendering safe and high
quality healthcare service through ongoing research evidences and innovations. An integrated,
continuous and coordinated healthcare delivery is useful in this regard (Jones and Killion 2017).
In the given scenario, clinical effectiveness could have been improved and well addressed had
there been a provision of a simulation-based strategy for implementation in clinical and
educational sector. Knowledge based and rule-based errors might be well allayed by investing in
such procedures and has been regarded as a crucial tool for abating error-prone situations like
that of medication administration (Keers et al. 2013).
Improved workforce within the clinical healthcare team might allow for a better output in
terms of facilitating the provision of adequate healthcare service to the patients. Modern
interdisciplinary approaches are being increasingly emphasized in the clinical settings to harbor
optimal outcomes. Management of clinical standards in an adept manner through increased
collaboration with the healthcare workforce is fostered through abidance of a multi-professional

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healthcare framework (Kennedy et al. 2017). It has been recognized that facilitation of learning
of evidence based practice principles is dependent upon the engagement of the related workforce
within the clinical setting. Clinicians, nurses in addition to the inter-professional students have
been suggested to play crucial role in maintaining effective workforce so that the clinical
outcomes may be greatly improved (McKeever et al. 2016). In the given scenario, lack of on-site
support as desirable from the nursing attendants also contributed to the emanation of medication
error. Orientation of new staff members was also not done in the give context that added to the
cause of medication error. The coalition, unity and adequate professional knowledge and training
amongst the registered nurses and attending nurses might have helped n evading the situation to
some extent.
Risk management is another aspect of clinical governance that attends to the
conformance of various safety principles to ensure that the patients receives utmost care facility
without posing threats or harms to their health. Governance roles as well as management and
practice roles are essential in ensuring that the risk assessment and subsequent tasks are
appropriately conducted (Brennan and Flynn 2014). Advocacy of a patient safety culture may be
gained through training of the healthcare staff who are directly associated and responsible for
conferring healthcare service to the patients depending upon their needs and circumstances
(Sendlhofer et al. 2015). In the given scenario, the lack of adequate training and orientation
course for the newly appointed registered nurse for increasing the familiarity with the near
environment might have been beneficial in preventing the risk associated with medication
administration.
The promotion of clinical excellence is directly related with the interaction of a plethora
of factors such as those encompassing principles of consumer participation, clinical

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effectiveness, effective workforce and risk management that underlie the clinical governance
aspect. Emphasis must be laid on each of these components to render safety and quality
healthcare service to the patients.

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References
Ahmed, M., Arora, S., Tiew, S., Hayden, J., Sevdalis, N., Vincent, C. and Baker, P., 2014.
Building a safer foundation: the Lessons Learnt patient safety training programme. BMJ Qual
Saf, 23(1), pp.78-86.
Brennan, N.M. and Flynn, M.A., 2013. Differentiating clinical governance, clinical management
and clinical practice. Clinical Governance: An International Journal, 18(2), pp.114-131.
Gluyas, H. and Morrison, P., 2014. Human factors and medication errors: a case study. Nursing
Standard, 29(15), pp.37-42.
Hamer, S. and Collinson, G., 2014. Achieving Evidence-Based Practice E-Book: A Handbook
for Practitioners. Elsevier Health Sciences.
Harris, C., Ko, H., Waller, C., Sloss, P. and Williams, P., 2017. Sustainability in Health care by
Allocating Resources Effectively (SHARE) 4: Exploring opportunities and methods for
consumer engagement in resource allocation in a local 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. and Keenan, G.M., 2014. Health
data use, stewardship, and governance: ongoing gaps and challenges: a report from AMIA's 2012
Health Policy Meeting. Journal of the American Medical Informatics Association, 21(2), pp.204-
211.
Jones, A. and Killion, S., 2017. title Clinical governance for Primary Health Networks.

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Keers, R.N., Williams, S.D., Cooke, J. and Ashcroft, D.M., 2013. Prevalence and nature of
medication administration errors in health care settings: a systematic review of direct
observational evidence. Annals of Pharmacotherapy, 47(2), pp.237-256.
Kennedy, M., Elcock, M., Ellis, D. and Tall, G., 2017. Pre‐hospital and retrieval medicine:
Clinical governance and workforce models. Emergency Medicine Australasia.
McKeever, S., Twomey, B., Hawley, M., Lima, S., Kinney, S. and Newall, F., 2016. Engaging a
Nursing Workforce in Evidence‐Based Practice: Introduction of a Nursing Clinical Effectiveness
Committee. Worldviews on Evidence
‐Based Nursing, 13(1), pp.85-88.
Sendlhofer, G., Brunner, G., Tax, C., Falzberger, G., Smolle, J., Leitgeb, K., Kober, B. and
Kamolz, L.P., 2015. Systematic implementation of clinical risk management in a large university
hospital: the impact of 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. Nursing unit teams matter: Impact of unit-level nurse practice environment, nurse work
characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient
adverse events—A cross-sectional survey. International journal of nursing studies, 51(8),
pp.1123-1134.