Medication Safety & Medical Error
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AI Summary
This article discusses the importance of medication safety and reducing medical errors in promoting clinical excellence. It analyzes a patient's narrative on medication safety and the consequences of medical errors. The role of clinical governance in ensuring patient safety is also explored.
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Running Head: MEDICATION SAFETY & MEDICAL ERROR
MEDICATION SAFETY & MEDICAL ERROR
MEDICATION SAFETY & MEDICAL ERROR
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MEDICATION SAFETY & MEDICAL ERROR
Introduction
In order to promote clinical excellence, it is impertinent that medical errors are reduced
and medication safety is administered (Choo, Hutchinson & Bucknall, 2010). In the current
scope of discussion a patient's mother narrative has been analyzed related to the safety of health
care. The video is seen on YouTube and was produced for labor-management patient safety
project on medication safety (cirSEIU, 2012). The patient story was related to an actual
breakdown in care resulting in the death of Lewis, a healthy 15-year-old boy.
Patient Story
The narrative was described by the patient’s mother. She recalls the horrifying experience
of what happened to her son at the hospital. Her son Lewis was a healthy 15-year-old boy, who
played soccer, was a top student in Columbia, SC metro area and he also acted in the community
theater. Back at home he was easy-going, very popular amongst his peers, and had a very good
sense of humor.
He was taken to the hospital after a cosmetic condition and he was slightly dehydrated at
that time. After the surgery, he was not producing urine, though his parents reported regarding
the same, there was no doctor visiting him (Gaal, Verstappen & Wensing, 2011). He failed to
urinate after the surgery and it took him two days prior to changing orders amongst the staffs to
increase his fluids to provide adequate dosage. He continued to be in pain after the surgery and
was not able to urinate. Lewis weighed 120 pounds and was provided with an adult dosage of
NSAID ketorolac tromethamine to reduce his pain. At this juncture, Lewis is seen to be given
inappropriate drug without considering for patient safety. His narcotics levels are continuously
2
Introduction
In order to promote clinical excellence, it is impertinent that medical errors are reduced
and medication safety is administered (Choo, Hutchinson & Bucknall, 2010). In the current
scope of discussion a patient's mother narrative has been analyzed related to the safety of health
care. The video is seen on YouTube and was produced for labor-management patient safety
project on medication safety (cirSEIU, 2012). The patient story was related to an actual
breakdown in care resulting in the death of Lewis, a healthy 15-year-old boy.
Patient Story
The narrative was described by the patient’s mother. She recalls the horrifying experience
of what happened to her son at the hospital. Her son Lewis was a healthy 15-year-old boy, who
played soccer, was a top student in Columbia, SC metro area and he also acted in the community
theater. Back at home he was easy-going, very popular amongst his peers, and had a very good
sense of humor.
He was taken to the hospital after a cosmetic condition and he was slightly dehydrated at
that time. After the surgery, he was not producing urine, though his parents reported regarding
the same, there was no doctor visiting him (Gaal, Verstappen & Wensing, 2011). He failed to
urinate after the surgery and it took him two days prior to changing orders amongst the staffs to
increase his fluids to provide adequate dosage. He continued to be in pain after the surgery and
was not able to urinate. Lewis weighed 120 pounds and was provided with an adult dosage of
NSAID ketorolac tromethamine to reduce his pain. At this juncture, Lewis is seen to be given
inappropriate drug without considering for patient safety. His narcotics levels are continuously
2
MEDICATION SAFETY & MEDICAL ERROR
increased as he maintains high levels of pain. This was considered to be very dangerous as he
was faced with high fluid deficiency.
After three days of the surgery, Lewis complains regarding severe, unremitting epigastric
pain and no attention was paid to him. The nurses, residents along with other staffs did not act
when Lewis showed increasing signs of instability. Lewis is seen to have dark circles under his
eyes and he is unable to walk . He starts feeling tremendously weak and is still left unattended by
staffs. He feels agonizing pain and has cold sweats. His belly seems to be distended and he has
no bowel sounds. His respiratory rate is very high and is still not attended. His parents
continually request for the attending physician but no one comes to their rescue. Even at this
stage, Lewis is not attended over two days period.
Lewis is unable to sustain his condition and dies. His autopsy reports revealed a giant
duodenal ulcer. It was with 2.8 liters of gastric and blood secretions in the peritoneal cavity, it
was consistent with an NSAID overdose. The primary contributing factor of Lewis decline was
identified to be unfamiliarity with reaction and dosing of the drug and medical contradictions
with side effects. Further, there were no nurses adequately trained, who could challenge the
incorrect orders, change the plans and intervene on a patient (Patel & Balkrishnan, 2010). The
physicians, as well as the nurses, failed to assess, intervene and escalate even in case of the
alarming condition. They could not identify signs of sepsis and shock with Lewis deteriorating
condition. They never called a code in it was necessary. The nurses lacked awareness of the
situation, failed to communicate, or escalate and finally rescue the boy from his condition.
Analysis of care & contextual factors inpatient
3
increased as he maintains high levels of pain. This was considered to be very dangerous as he
was faced with high fluid deficiency.
After three days of the surgery, Lewis complains regarding severe, unremitting epigastric
pain and no attention was paid to him. The nurses, residents along with other staffs did not act
when Lewis showed increasing signs of instability. Lewis is seen to have dark circles under his
eyes and he is unable to walk . He starts feeling tremendously weak and is still left unattended by
staffs. He feels agonizing pain and has cold sweats. His belly seems to be distended and he has
no bowel sounds. His respiratory rate is very high and is still not attended. His parents
continually request for the attending physician but no one comes to their rescue. Even at this
stage, Lewis is not attended over two days period.
Lewis is unable to sustain his condition and dies. His autopsy reports revealed a giant
duodenal ulcer. It was with 2.8 liters of gastric and blood secretions in the peritoneal cavity, it
was consistent with an NSAID overdose. The primary contributing factor of Lewis decline was
identified to be unfamiliarity with reaction and dosing of the drug and medical contradictions
with side effects. Further, there were no nurses adequately trained, who could challenge the
incorrect orders, change the plans and intervene on a patient (Patel & Balkrishnan, 2010). The
physicians, as well as the nurses, failed to assess, intervene and escalate even in case of the
alarming condition. They could not identify signs of sepsis and shock with Lewis deteriorating
condition. They never called a code in it was necessary. The nurses lacked awareness of the
situation, failed to communicate, or escalate and finally rescue the boy from his condition.
Analysis of care & contextual factors inpatient
3
MEDICATION SAFETY & MEDICAL ERROR
Safety in dealing with a patient is based on process and experience. The Significant Event
Audit (SEA) offers the most comprehensive process for evaluating a patient’s condition (McKay,
Bradley, Lough & Bowie, 2009). Evaluating the patient's case using the SEA, a qualitative
evaluation can be constructed. The seven stages of SEA includes;
Awareness and prioritization of the significant event is the first step. In this case, the
nurses nor the clinical staffs made the patient's case a priority through the patient condition was
deteriorating significantly. The staffs and nurses should have prioritized the case and taken an
urgent decision for the patient.
Information gathering. Members need to gather information relevant to the case, to
identify and prioritize the significant event in a confident manner (Bowie et al, 2016). The
nurse’s neither did other clinical staff was able to diagnose the urgency of the patient's severity.
The nurses did not prioritize the event an treated the patient at par with general patients even in
his deteriorating condition.
The facilitated team-based meeting as few people has access to data and information.
Practicing a computer-based system for logging significant cases, which is available to staff and
conducting team-based meeting (Gillam & Siriwardena, 2013). There was no mention of
computer records for the case or any case being mentioned in the video. This implies that the
patient case was not adequately provided and nurses were not aware of the patient's health
condition.
4
Safety in dealing with a patient is based on process and experience. The Significant Event
Audit (SEA) offers the most comprehensive process for evaluating a patient’s condition (McKay,
Bradley, Lough & Bowie, 2009). Evaluating the patient's case using the SEA, a qualitative
evaluation can be constructed. The seven stages of SEA includes;
Awareness and prioritization of the significant event is the first step. In this case, the
nurses nor the clinical staffs made the patient's case a priority through the patient condition was
deteriorating significantly. The staffs and nurses should have prioritized the case and taken an
urgent decision for the patient.
Information gathering. Members need to gather information relevant to the case, to
identify and prioritize the significant event in a confident manner (Bowie et al, 2016). The
nurse’s neither did other clinical staff was able to diagnose the urgency of the patient's severity.
The nurses did not prioritize the event an treated the patient at par with general patients even in
his deteriorating condition.
The facilitated team-based meeting as few people has access to data and information.
Practicing a computer-based system for logging significant cases, which is available to staff and
conducting team-based meeting (Gillam & Siriwardena, 2013). There was no mention of
computer records for the case or any case being mentioned in the video. This implies that the
patient case was not adequately provided and nurses were not aware of the patient's health
condition.
4
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Problem
Wrong Medicine Used Wrong Medicine
Dosage Used
Absence of fluid
monitoring
Negligence of nurses,
physicians &
healthcare staffs Absence of physician
monitoring Lack of integrating
parents feedback
MEDICATION SAFETY & MEDICAL ERROR
Figure 1: Fishbone Diagram
Analysis of the significant event. It is necessary that the significant event is diagnosed and
then analysed on actual potential consequences for quality patient care (Scott, 2009). It can be
said that the patient’s case deteriorated as the nurses and physicians failed to act when needed to.
None of the staffs or nurses identified the consequences or provide adequate care to the patient.
Agree, implement and monitor change Over-representation of heavily clinical material
for audit alienating non-clinical staffs and ignoring flexibility. In this case, it was integral that
different team combinations are made on the nature of the event. Reporting failure regarding the
team has to be identified as well. The changes agreed by the various nurses and clinical staffs
needs to be implemented and then the changes be monitored.
Write it up is an integral stage for implementing change process. Other clinical and
healthcare staffs did not contribute to the patient case. There was complete ignorance of the
patient safety and administration of appropriate dosage which could improvise his health
5
Wrong Medicine Used Wrong Medicine
Dosage Used
Absence of fluid
monitoring
Negligence of nurses,
physicians &
healthcare staffs Absence of physician
monitoring Lack of integrating
parents feedback
MEDICATION SAFETY & MEDICAL ERROR
Figure 1: Fishbone Diagram
Analysis of the significant event. It is necessary that the significant event is diagnosed and
then analysed on actual potential consequences for quality patient care (Scott, 2009). It can be
said that the patient’s case deteriorated as the nurses and physicians failed to act when needed to.
None of the staffs or nurses identified the consequences or provide adequate care to the patient.
Agree, implement and monitor change Over-representation of heavily clinical material
for audit alienating non-clinical staffs and ignoring flexibility. In this case, it was integral that
different team combinations are made on the nature of the event. Reporting failure regarding the
team has to be identified as well. The changes agreed by the various nurses and clinical staffs
needs to be implemented and then the changes be monitored.
Write it up is an integral stage for implementing change process. Other clinical and
healthcare staffs did not contribute to the patient case. There was complete ignorance of the
patient safety and administration of appropriate dosage which could improvise his health
5
MEDICATION SAFETY & MEDICAL ERROR
conditions. A report will serve as a written document for other patient care in the future at the
healthcare center.
Report, share and review, once the report has been prepared, it needs to be shared and
reviewed (Menon & Williams, 2010). The sharing and review of the new process would enable
others in the healthcare center to implement better patient care in the future. The report will be
shared amongst various stakeholders of the organisation.
Clinical Governance Role
Clinical governance plays a distinct role to support safe and effective along with person-
centered care for patients. Its concepts remain embedded in primary care and pursue excellence
for healthcare organizations (Boluarte, 2009). Clinical governance encompasses a set of systems
and procedures for improvisation of patient care. Application of clinical governance, especially
nursing leadership can create a differential impact on nursing care. In the above discussed patient
care, nursing leadership would have enabled nurses to take on more proactive roles such that
they assume greater responsibility for patient cases. Nurses would have taken greater
accountability for their practice. As in the above case, none of the nurses took responsibility and
failed to identify the problems faced by the patient, such case would not have arisen (Travaglia,
Debono, Spigelman & Braithwaite, 2011). Nurses would have to integrate audit and follow
prescribed indications willing to maintain high standards in quality care. Reflecting on practice
through self-criticism and constructive learning from mistakes is a basic framework for clinical
governance effective application. Nurses and other staffs needs to work across interfaces such
that they are able to overcome traditional boundaries in health and social care.
6
conditions. A report will serve as a written document for other patient care in the future at the
healthcare center.
Report, share and review, once the report has been prepared, it needs to be shared and
reviewed (Menon & Williams, 2010). The sharing and review of the new process would enable
others in the healthcare center to implement better patient care in the future. The report will be
shared amongst various stakeholders of the organisation.
Clinical Governance Role
Clinical governance plays a distinct role to support safe and effective along with person-
centered care for patients. Its concepts remain embedded in primary care and pursue excellence
for healthcare organizations (Boluarte, 2009). Clinical governance encompasses a set of systems
and procedures for improvisation of patient care. Application of clinical governance, especially
nursing leadership can create a differential impact on nursing care. In the above discussed patient
care, nursing leadership would have enabled nurses to take on more proactive roles such that
they assume greater responsibility for patient cases. Nurses would have taken greater
accountability for their practice. As in the above case, none of the nurses took responsibility and
failed to identify the problems faced by the patient, such case would not have arisen (Travaglia,
Debono, Spigelman & Braithwaite, 2011). Nurses would have to integrate audit and follow
prescribed indications willing to maintain high standards in quality care. Reflecting on practice
through self-criticism and constructive learning from mistakes is a basic framework for clinical
governance effective application. Nurses and other staffs needs to work across interfaces such
that they are able to overcome traditional boundaries in health and social care.
6
MEDICATION SAFETY & MEDICAL ERROR
The core aim of clinical governance is an enhancement of patient satisfaction, with the
application of such aims safety and care of the patient can be brought about in focus (Smith,
Latter & Blenkinsopp, 2014). Clinical governance application also enables to learn from others,
with a willingness to look outside one’s practice. Nurse for the above patient could have assumed
greater responsibility in consulting other nurses or staffs, who have prior experience in patient
safety. This would have supported the development of not only learning networks but could have
possibly saved the life of the boy. The specific areas for clinical governance includes leadership
skills, communication and talent to influence people. Some other factors include effective
communication systems amongst primary and secondary care, access to clinical information and
a multi-professional approach with management support.
It is also required that users are involved in catering to clinical governance (Dückers et al,
2009). As in the above case, it is seen that the parents of the patient were not paid any attention
to, this is against clinical governance. In accordance with clinical governance, it is required to
focus on partnering with patients for their greater participation and sensitivity to user needs.
Moreover, the evidence-based practice could have been accommodated, which was totally absent
in the case (Coombes, Stowasser, Reid & Mitchell, 2009). Clinical governance encompasses a
set of systems and procedures for improvisation of patient care. It can be said that the application
of clinical governance could have allowed more patient-related outcome and adherence to the
safe procedure for the patient.
Conclusion
To conclude, it can be said that medication safety has gained tremendous importance in
the recent time period. Nurses and other clinical staffs need to be aware of various medications
7
The core aim of clinical governance is an enhancement of patient satisfaction, with the
application of such aims safety and care of the patient can be brought about in focus (Smith,
Latter & Blenkinsopp, 2014). Clinical governance application also enables to learn from others,
with a willingness to look outside one’s practice. Nurse for the above patient could have assumed
greater responsibility in consulting other nurses or staffs, who have prior experience in patient
safety. This would have supported the development of not only learning networks but could have
possibly saved the life of the boy. The specific areas for clinical governance includes leadership
skills, communication and talent to influence people. Some other factors include effective
communication systems amongst primary and secondary care, access to clinical information and
a multi-professional approach with management support.
It is also required that users are involved in catering to clinical governance (Dückers et al,
2009). As in the above case, it is seen that the parents of the patient were not paid any attention
to, this is against clinical governance. In accordance with clinical governance, it is required to
focus on partnering with patients for their greater participation and sensitivity to user needs.
Moreover, the evidence-based practice could have been accommodated, which was totally absent
in the case (Coombes, Stowasser, Reid & Mitchell, 2009). Clinical governance encompasses a
set of systems and procedures for improvisation of patient care. It can be said that the application
of clinical governance could have allowed more patient-related outcome and adherence to the
safe procedure for the patient.
Conclusion
To conclude, it can be said that medication safety has gained tremendous importance in
the recent time period. Nurses and other clinical staffs need to be aware of various medications
7
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MEDICATION SAFETY & MEDICAL ERROR
along with their side effects. While administering any sort of pain-related drugs especially there
has to be conducted a comprehensive analysis undertaken by nurses so as to prevent medical
errors and patient's suffering.
8
along with their side effects. While administering any sort of pain-related drugs especially there
has to be conducted a comprehensive analysis undertaken by nurses so as to prevent medical
errors and patient's suffering.
8
MEDICATION SAFETY & MEDICAL ERROR
References
Boluarte, T. A. (2009). The emotional impact of medical error involvement on physicians: a call
for leadership and organizational accountability. Swiss medical weekly, 139(0102).
Retrieved from
https://smw.ch/resource/jf/journal/file/view/article/smw/en/smw.2009.12417/
d4e7a3ae1b1683fbd4734fe7c3acc6a30831cf61/smw.2009.12417.pdf/
Bowie, P., McNaughton, E., Bruce, D., Holly, D., Forrest, E., Macleod, M., Kennedy, S., Power,
A., Toppin, D., Black, I. and Pooley, J. (2016). Enhancing the effectiveness of significant
event analysis: exploring the personal impact and applying systems thinking in primary
care. The Journal of continuing education in the health professions, 36(3), 195. doi:
10.1097/CEH.000000000000098. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063067/
Choo, J., Hutchinson, A., & Bucknall, T. (2010). Nurses' role in medication safety. Journal of
nursing management, 18(7), 853-861. doi: 10.1111/j.1365-2834.2010.01164.x. Retrieved
from https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2834.2010.01164.x
cirSEIU. [Sep 6, 2012]. Medication Safety: A Patient’s Story. Retrieved from
<https://youtu.be/CspIrlJ2bd4>
Coombes, I. D., Stowasser, D. A., Reid, C., & Mitchell, C. A. (2009). Impact of a standard
medication chart on prescribing errors: a before-and-after audit. BMJ Quality &
Safety, 18(6), 478-485. doi: 10.1136/qshc.2007.025296. Retrieved from
https://qualitysafety.bmj.com/content/18/6/478.short
9
References
Boluarte, T. A. (2009). The emotional impact of medical error involvement on physicians: a call
for leadership and organizational accountability. Swiss medical weekly, 139(0102).
Retrieved from
https://smw.ch/resource/jf/journal/file/view/article/smw/en/smw.2009.12417/
d4e7a3ae1b1683fbd4734fe7c3acc6a30831cf61/smw.2009.12417.pdf/
Bowie, P., McNaughton, E., Bruce, D., Holly, D., Forrest, E., Macleod, M., Kennedy, S., Power,
A., Toppin, D., Black, I. and Pooley, J. (2016). Enhancing the effectiveness of significant
event analysis: exploring the personal impact and applying systems thinking in primary
care. The Journal of continuing education in the health professions, 36(3), 195. doi:
10.1097/CEH.000000000000098. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063067/
Choo, J., Hutchinson, A., & Bucknall, T. (2010). Nurses' role in medication safety. Journal of
nursing management, 18(7), 853-861. doi: 10.1111/j.1365-2834.2010.01164.x. Retrieved
from https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2834.2010.01164.x
cirSEIU. [Sep 6, 2012]. Medication Safety: A Patient’s Story. Retrieved from
<https://youtu.be/CspIrlJ2bd4>
Coombes, I. D., Stowasser, D. A., Reid, C., & Mitchell, C. A. (2009). Impact of a standard
medication chart on prescribing errors: a before-and-after audit. BMJ Quality &
Safety, 18(6), 478-485. doi: 10.1136/qshc.2007.025296. Retrieved from
https://qualitysafety.bmj.com/content/18/6/478.short
9
MEDICATION SAFETY & MEDICAL ERROR
Dückers, M., Faber, M., Cruijsberg, J., Grol, R., Schoonhoven, L., & Wensing, M. (2009). Safety
and risk management interventions in hospitals. Medical care research and
review, 66(6_suppl), 90S-119S. doi: 10.1177/1077558709345870. Retrieved from
https://journals.sagepub.com/doi/abs/10.1177/1077558709345870
Gaal, S., Verstappen, W., & Wensing, M. (2011). What do primary care physicians and
researchers consider the most important patient safety improvement strategies?. BMC
health services research, 11(1), 102. doi: 10.1186/1472-6963-11-102. Retrieved from
https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-11-102
Gillam, S., & Siriwardena, A. N. (2013). Frameworks for improvement: clinical audit, the plan-
do-study-act cycle and significant event audit. Quality in Primary Care, 21(2).
McKay, J., Bradley, N., Lough, M., & Bowie, P. (2009). A review of significant events analyzed
in general practice: implications for the quality and safety of patient care. BMC family
practice, 10(1), 61. doi: 10.1186/1471-2296-10-61. Retrieved from
https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-10-61
Menon, K., & Williams, D. D. (2010). Investor reaction to going concern audit reports. The
Accounting Review, 85(6), 2075-2105. doi: 10.2308/accr.2010.85.6.2075. Retrieved from
https://www.aaajournals.org/doi/abs/10.2308/accr.2010.85.6.2075
Patel, I., & Balkrishnan, R. (2010). Medication error management around the globe: an
overview. Indian journal of pharmaceutical sciences, 72(5), 539. doi: 10.4103/0250-
474X.78518. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116296/
10
Dückers, M., Faber, M., Cruijsberg, J., Grol, R., Schoonhoven, L., & Wensing, M. (2009). Safety
and risk management interventions in hospitals. Medical care research and
review, 66(6_suppl), 90S-119S. doi: 10.1177/1077558709345870. Retrieved from
https://journals.sagepub.com/doi/abs/10.1177/1077558709345870
Gaal, S., Verstappen, W., & Wensing, M. (2011). What do primary care physicians and
researchers consider the most important patient safety improvement strategies?. BMC
health services research, 11(1), 102. doi: 10.1186/1472-6963-11-102. Retrieved from
https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-11-102
Gillam, S., & Siriwardena, A. N. (2013). Frameworks for improvement: clinical audit, the plan-
do-study-act cycle and significant event audit. Quality in Primary Care, 21(2).
McKay, J., Bradley, N., Lough, M., & Bowie, P. (2009). A review of significant events analyzed
in general practice: implications for the quality and safety of patient care. BMC family
practice, 10(1), 61. doi: 10.1186/1471-2296-10-61. Retrieved from
https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-10-61
Menon, K., & Williams, D. D. (2010). Investor reaction to going concern audit reports. The
Accounting Review, 85(6), 2075-2105. doi: 10.2308/accr.2010.85.6.2075. Retrieved from
https://www.aaajournals.org/doi/abs/10.2308/accr.2010.85.6.2075
Patel, I., & Balkrishnan, R. (2010). Medication error management around the globe: an
overview. Indian journal of pharmaceutical sciences, 72(5), 539. doi: 10.4103/0250-
474X.78518. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116296/
10
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MEDICATION SAFETY & MEDICAL ERROR
Scott, I. (2009). What are the most effective strategies for improving quality and safety of health
care?. Internal medicine journal, 39(6), 389-400. doi: 10.1111/j.1445-
5994.2008.01798.x. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-5994.2008.01798.x
Smith, A., Latter, S., & Blenkinsopp, A. (2014). Safety and quality of nurse independent
prescribing: a national study of experiences of education, continuing professional
development clinical governance. Journal of advanced nursing, 70(11), 2506-2517. doi:
10.1111/jan.12392. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12392
Travaglia, J. F., Debono, D., Spigelman, A. D., & Braithwaite, J. (2011). Clinical governance: a
review of key concepts in the literature. Clinical Governance: An International
Journal, 16(1), 62-77. doi: 10.1108/1477727111114592. Retrieved from
https://www.emeraldinsight.com/doi/abs/10.1108/14777271111104592
11
Scott, I. (2009). What are the most effective strategies for improving quality and safety of health
care?. Internal medicine journal, 39(6), 389-400. doi: 10.1111/j.1445-
5994.2008.01798.x. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-5994.2008.01798.x
Smith, A., Latter, S., & Blenkinsopp, A. (2014). Safety and quality of nurse independent
prescribing: a national study of experiences of education, continuing professional
development clinical governance. Journal of advanced nursing, 70(11), 2506-2517. doi:
10.1111/jan.12392. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12392
Travaglia, J. F., Debono, D., Spigelman, A. D., & Braithwaite, J. (2011). Clinical governance: a
review of key concepts in the literature. Clinical Governance: An International
Journal, 16(1), 62-77. doi: 10.1108/1477727111114592. Retrieved from
https://www.emeraldinsight.com/doi/abs/10.1108/14777271111104592
11
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