Promoting Clinical Excellence

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

1PROMOTING CLINICAL EXCELLENCE
Introduction:
The aim of this study is to analyze a personal experience (Using the Fishbone Model)
of an incident caused due to failure in the delivery of appropriate and safe care for a patient
resulting in an accident (Luo et al., 2018). The case study would be analyzed following the
London Protocol and outline the information related to the experience and event according to
what happened, individuals who were involved, when the incident occurred, severity of the
potential or actual harm, possibility of recurrence and the consequences of the event (Lamba
et al., 2014). The risk factors are then analyzed using the Fishbone model to identify how the
safety and quality of care can be improved under clinical governance frameworks (Currie et
al., 2017).
Case Study:
The incident took place when I was working as a trainee in the emergency
department, when an elderly male patient (Ethnicity: Aboriginal), aged 80 years old (Mr X)
presented with a case of accidental injury due to a fall and resulted in a broken radial bone on
the right hand. The patient was suffering from Dementia, and is mobility and gait was
affected due to his condition. Mr X was given a rolling walker to aid his balance and gait,
however, he forgot to take the walker with him while going to the toilet, slipped and fell. He
broke his right radial bone while trying to break his fall and it hit the basin. Mr X was in a lot
of pain when he arrived and was promptly given sedatives. After talking to the family of Mr
X (his wife and daughter), it was found that the walker was given to him a month ago, after
he fell while getting out of the bed and hurt his head and that a risk assessment of the
patient’s house was not performed to identify and address the fall hazards. Further assessment
of the patient revealed that his motor reflexes are poor leading to improper hand to eye
coordination, which increased his risks of falling. The incident occurred in the morning that

2PROMOTING CLINICAL EXCELLENCE
day, when the patient was conducting his activities of daily living. The fall occurred because
the patient was unable to balance himself and the floor of the toilet was slippery. With the
type of fall the patient took, it could be understood that under the given conditions, the fall
could have had serious and even fatal consequences. Moreover, due to his condition and the
patient is still at high risks of falling with the possibility of even more serious outcomes. This
shows a failure of the healthcare organization in the providence of safe and quality care for
the patient in the previous health encounter (Taylor et al., 2017).