University Nursing Report: Clinical Reasoning Errors in Patient Care

This report presents a detailed analysis of clinical reasoning errors encountered during a nursing clinical placement, focusing on a case study of a patient with dementia. The student identifies and discusses two key errors: anchoring bias, stemming from a misdiagnosis of delirium, and overconfidence bias among healthcare staff. The report explores the implications of these errors on patient care, including delayed or inappropriate treatment and potential harm. It references relevant literature to support the analysis and examines strategies for mitigating these errors, such as active information-seeking and self-awareness. The student reflects on the experience, highlighting the importance of critical thinking, thorough assessment, and continuous learning in nursing practice to improve patient outcomes and prevent future errors. The report concludes with a discussion on the importance of recognizing and addressing cognitive biases to enhance the quality of care.

Running head: PRACTICE PORTFOLIO OF EVIDENCE
PRACTICE PORTFOLIO OF EVIDENCE
Name of the Student:
Name of the University:
Author’s Note:

1PORTFOLIO OF EVIDENCE
In my recent clinical placement, a patient named Mr Johnson was admitted to the
hospital by his nephew, Sam, as his uncle had experienced difficulty breathing while he was
watching a cricket match. Mr. Johnson has had a history of Diabetes Mellitus for the past15
years; however, recently, he has forgotten to monitor his sugar level on time. Mr. Johnson
became anxious with his breathing difficulty, and his oxygen saturation level dropped below
95% leading to unconsciousness.
Mr. Johnson regained consciousness, where he demonstrated mental confusion and a violent
flare-up. After some time, he regained his composure and attained a stable mental status. He
was identified to have a condition where he forgets necessary details; for example, he forgot
his room number while returning from the toilet and had difficulty in conveying his emotions
and feelings to the healthcare professionals. After a thorough evaluation, medical
examination and consultation with family members, it was inferred from his behaviour,
which included agitation, aggression, confusion and disorientation that he was suffering from
delirium – this was misdiagnosed (Mukaetova-Ladinska et al., 2017). Mr Johnson was
confirmed to be diagnosed with dementia as both disorders (delirium and dementia) have
similar symptoms and affect the normal behaviour and functioning of the brain. According to
Caprio, Morrison and Poduri (2019), there is a subtle distinction between delirium and
dementia; therefore, in many cases, doctors and nurses are found to misjudge the condition
frequently.
Due to Mr. Johnson’s condition, the management of his blood sugar level is hampered
as he forgets to take his medicine on time. Another problem that was demonstrated by Mr
Johnson was the risk of injury to himself self as well as others that lead to compromising of
health. These two fundamental nursing problems in the case study form the basis for the goals
and nursing actions related to Mr. Johnson. These explicitly supported the patient and family
to address and mitigate the issues and thus improve the patient’s quality of life. Based on the

2PORTFOLIO OF EVIDENCE
case study, I have observed that there are two clinical reasoning errors, anchoring and
overconfidence bias. From my initial assessment, it was found that Mr. Johnson has delirium
because of a misdiagnosis of behavior. Later, we confirmed that he had dementia, indicating
that an anchoring error had occurred because of a nurse’s misdiagnosis.
From the case study demonstrated above, there has been the presence of clinical errors
that have affected the optimal quality of care of Mr. Johnson in the healthcare setting.
According to Norman et al. (2017), 5% to 14% of acute admission in hospitals were found to
have clinical errors such as missed or delayed care. Medical errors affect the delivery of
health care over a decade that include inaccurate or delayed diagnosis in offering care for
avoidance of unacceptable outcomes (Makary & Daniel, 2016). It is important to understand
the implications of such errors as in worst-case scenarios, which may lead to permanent
injury or even death. Most of the time, healthcare professionals do not intentionally commit
such mistakes; instead, they are caused due to a range of complex environmental or cognitive
factors that increase the possibility of their occurrence (Forsyth et al. 2017). The different
types of clinical reasoning errors are anchoring, confirmation bias, ascertainment bias,
premature closure, diagnostic momentum, overconfidence, fundamental attribution errors,
unpacking principles, and psych-out errors (Norman et al., 2017). Therefore, it is important to
address the issue in an appropriate manner for improving the quality of care in a care setting.
According to Richie and Josephson (2019), the tendency of focusing on the salient
features of the presentation of patient at a very early stage in the process of clinical reasoning
and failure to adjust the initial nursing judgement, in the light of new information, is
considered as anchoring. It is stated that the first impression influences all the practice, and
thus, its impact has a profound effect on the thought process as well as the actions that need
to be taken (Holmes 2016). After assessment and testing, it was later identified that the
condition was dementia, and an action plan related to this was formulated on an immediate

3PORTFOLIO OF EVIDENCE
basis. In this case, it was not identified on time, inappropriate medication and action plan
would have been proposed thus, delaying the possibility of recovery. The outcome would
have been poor quality of care, resulting in a longer stay in hospital, high cost, waste of time
and in severe cases (Dalton and Byrne, 2017). Mr. Johnson may have exhibited a violent
outburst that may have resulted in hurting himself or others. The strategy that can be used for
reducing errors based on anchoring is seeking information in an active manner that can
counter the current diagnosis decision based on the initial assessment. It is important to frame
a diagnostic thinking ability that will help in the avoidance of any premature labelling that
leads to premature closure (Howard 2019). In case, the staff are uncertain, it is critical to
discuss and share the uncertainties in order to make a definite decision.
The second error was related to overconfidence bias that was exhibited by healthcare
staff taking care of Mr Johnson, which may have had a negative impact unless timely
detection of the issue had not been made. According to Keijzers et al. (2018), the tendency of
acting upon incomplete information, diagnosis or intuition is called overconfidence, which is
subjective and objective in nature. The factors that play a role in this error involves our
arrogance, complacency and egocentrism. It is an obvious fact that both delirium and
dementia demonstrate similar kinds of symptoms. According to Farina et al. (2017), dementia
is a slow progressive disorder that involves decline of cognitive behaviour of an individual.
On the other hand, delirium is a sudden occurring disease whose symptoms fluctuate
throughout the day (Hshieh, Inouye & Oh 2018). The major difference between the two
disorders is inattention, where a person is unable to focus on a particular thing or idea for a
long time. It was noted in the case of Mr. Johnson that the healthcare professional was
overconfident and was biased with their skills and knowledge; consequently, they stated that
the patient was suffering from delirium. The ways in which such incidents may be avoided
include being observant in cognitive errors, self-awareness, accepting that mistakes can occur

4PORTFOLIO OF EVIDENCE
open-mindedness and flexibility to rectify and learn from the experience is important (Coope
& Frain 2017). In this particular case, these errors were not identified on time and it may
have had a disastrous impact on the patient’s outcome and led to a deterioration in the
patient’s condition.
From my clinical placement experience and exploration, I understood that there were issues
in the nursing practice and there is a requirement to reflect on these to enhance care quality. It
initiated a process of new learning that enhanced the thinking ability of a nurse to think like a
registered nurse (Lejonqvist, Eriksson and Meretoja, 2016). In my future nursing practice, I
would like to gain more information related to clinical reasoning errors that would allow me
to understand the probable medical mistakes and ways to mitigate them. I understand that for
offering competent and professional practice, along with psychomotor and affective ability,
there is a requirement for refined thinking abilities (Brundiers and Wiek, 2017). As a
registered nurse, significant judgment need to be made in a healthcare sector. Even as a
graduate nurse, it is important to make complex decisions for the care of patients with diverse
needs. The skill of clinical reasoning is key factor, as I found, which might have negative
outcome on patient’s health and well-being if not appropriately applied. As I found in this
case, partial assessment was taken into consideration for stating the disease. The physician
finally corrected the error where it was detected that the patient suffer from dementia. I was
so busy in observing the preliminary symptoms that I was unable to notice inattentiveness
that distinguishes one disease from the other. Thus, I failed in identification of vital
information and reporting, which resulted in an incorrect diagnosis. In the future, I will look
at the bigger picture and assess from head to toe in order to gain an evidence-based
assessment instead of concentrating on an initial assessment (Neal et al., 2016). It also states
that even if I had gained a thorough theoretical knowledge from my studies however, there is
more scope for learning and researching the various elements of clinical reasoning and the

5PORTFOLIO OF EVIDENCE
errors related to it. I was fortunate enough that my supervisor was able to identify the actual
disease Mr Johnston was suffering thus my judgement did not endanger the patient.
I have gained invaluable experience from the encounter, learnt the treatment process
that need to be followed. This process is to treat the patient without any predefined ideas or
thoughts and to make a thorough evaluation of their medical history and their present
scenario to understand the patient’s current health status In future I will not allow any kind
of biases that might cloud my logic and rational ability to make decision or infer any
conclusion. The strategies that will help in addressing the weakness is to gather various cues,
use all the details present in the case and align my knowledge with practice before
establishing any diagnosis. This will help in gaining a precise representation of the situation
of patient. Although it is not possible to eliminate all errors within my practice, however, the
above strategies need to be taken into account for offering care to the patient.

6PORTFOLIO OF EVIDENCE
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