University Clinical Error Analysis: Problem-Based Learning Report

This report provides a comprehensive analysis of a clinical error case study, focusing on the impact on a nurse (the 'second victim') and the healthcare organization. The report examines the short-term and long-term effects of the error, including the psychological impact on the nurse, damage to the organization's reputation, and potential legal consequences. It highlights the roles and responsibilities of unit managers and senior clinicians in supporting the affected nurse and preventing future errors. The report also discusses the impact of the event on team dynamics, organizational reporting and investigation processes, and the importance of healthcare organizations providing adequate support to staff involved in adverse events. It emphasizes the contribution of the second victim in identifying system flaws and improving patient safety, referencing relevant literature and research to support its findings.

Running head: PROBLEM-BASED LEARNING
PROBLEM-BASED LEARNING
Name of the Student:
Name of the University:
Author note:

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Description of Clinical scenario
I was working as a professional nurse and had joined the organization 6 months back.
During my regular shift activity I noticed that one of my senior colleague waiting outside the
unit manager room and was upset. After speaking to her, I got to know that she was charged
and blamed for conducting a clinical error that had resulted in an adverse event. She was a
long-term practitioner in the children hospital and one of her patient died due to medication
overdose for which she was blamed of being careless and ignorant (Scott et al., 2009). Her
licence was cancelled and she lost her job. She was in a state of depression as she had also
lost her livelihood. She was working in the organization for more than 2 year and had no
history of malpractice or error. The mental condition of the nurse was getting deteriorated
and she had eventually committed suicide after 5 months of the child’s death. The child who
died and his family members were considered as the first victim and the second victim in this
case was the nurse and the healthcare practitioners who were involved in the incident and
were personally accountable for the complete situation (Wu, 2000). The incidence of clinical
error depends on the intensity and severity of the outcome that will determine what
consequence should be faced by the second victim. In this scenario, the mother of nurse
stated that she lacked coping skills and was over-burdened with work that could be possible
due to work overload and no adequate support. The level of safety managed by the hospital
depends on the way the organization handle and deal with the second victim. The hospital
had suspended the second victim, which stated that they had fear, anxiety and lack of
willingness to learn from their mistakes. Hence, the organization did not support the second
victim or helped her to overcome from the psychological illness.

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Short term and long-term impact
The above case scenario highlights the situation of clinical error, which has a long-
term as well as short-term effect on the second victim that comprise of the nurse who was
responsible for the deed and the healthcare practitioners. The clinical error has a negative
influence on other patients who are present in the hospital and are scared to receive treatment
from the involved healthcare professionals, which eventually ruins the decorum of the
organization. The major long-term effect is that the reputation and the trust of the healthcare
organization are questioned and the organization might also face some legal consequences
(Chamoun, Zeenny & Mansour, 2016). The short term effect is that the second victims
(healthcare practitioner and nurse) suffer from the feeling of guilt and even doubt their
individual capabilities that in turn effect their mental health and peace. In case of any adverse
event, the second victim might also lose their job that will affect their personal lives and they
can even have a bad reputation within the society. In the long run the organization has to deal
with the negative image and in case of adverse situation, the license of the organization might
also be cancelled (Wu, 2000).
Role and responsibilities of unit managers and senior clinicians
The primary role and responsibility of the unit managers and senior clinicians who are
involved in the adverse event is that they should provide adequate support and assistance to
the nurse. In this case scenario, the nurse was not all supported by the organization because of
which she was in the state of depression and even committed suicide. Therefore, it is the
primary responsibility of the unit managers and senior clinicians to support the second victim
and help them to learn from their mistakes (Santomauro, Kalkman & Dekker, 2014). The
senior clinicians can set up a second victim program or employee assistance program, where
they will educate the nurses and the practitioners to fulfil the gap and emphasize on

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improving their self-ability to handle different patient effectively. The second victim solely
require emotional and social support from the organization that involve the unit managers and
senior clinicians as they are under mental stress and require one-to-one counselling and
support. After the adverse event, the nurse require immediate assistance and guidance form
the senior faculty or healthcare providers that will guide the staff and help them to overcome
from the negative impact of the events (Scott et al., 2009).
Impact of the event
The activity of the clinical error has a negative or bad influence on the team dynamics
and communication that hampers the competency and trust of the organization. The
organization works by adapting the input-process-output (IPO) model, which states that there
is a direct relationship among the organization culture (I), interprofessional teamwork (P) and
job satisfaction (O) (Kirklin et al., 2017). Therefore, in case of clinical error, the
organizational culture is hampered with zero job satisfaction that ultimately hamper the team
work also, as the involved team members are questioned. In such situation everyone wants to
stay out of the issue hence nobody communicate or get involved that disturb the dynamics of
the organization. The involved staff members lose trust of their senior staff members and the
organization that in turn decreases the competency of the organization and the hamper the
organizational culture (Kable, Kelly & Adams, 2018).
Organisational reporting and investigation
In this case of any clinical error, it is the responsibility of the organization to carry out
the investigation and find out what is the exact reason for the demise of the patient and also
report the event accordingly. The organization should adopt mandatory reporting system that
will focus on the identification of the series of events that was responsible for the clinical
error (Stavropoulou, Doherty & Tosey, 2015). According to the mandatory reporting system,

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it is the responsibility of the organization to provide report that encompass all the series of
events that resulted in clinical error and also highlight the reason that was majorly responsible
for the action as the report is difficult to conceal and easy to recognize. In this case scenario,
mandatory reporting system would be beneficial to highlight the activity that was performed
by the nurse and what factors were responsible for the event. According to the nurse’s
mother, the nurse lacked coping skills, which means that either she was over-burned with
work or maybe she was assigned with difficult task which was out of her expertise. Hence, it
is the responsibility of the organization to conduct an external report that will highlight this
factor and help the second victim from facing extreme consequences (Makary & Daniel,
2016).
Support from healthcare organization
The healthcare organization should provide adequate support and assistance to the
staff members or the nurses who are accountable for the action, as the nurses are already in
the state of shock and majority of them suffer from psychological stress sand misbalance.
Therefore, the organization should set up a psychological counselling and support assistance
that will guide and help the nurse to overcome from the mental trauma (Sirriyeh et al., 2010).
The organization should conduct a detailed investigation and evaluate if the accountable
nurse is solely responsible and if some other associated factor should be considered in this
activity. The organization should provide a clinical supervisor to the nurse and the supervisor
will be accountable for checking and evaluating if the nurse was really responsible or not and
what severity of adverse events took place, as the nurse require emotional and social support
(Scott, Hirschinger & Cox, 2008). Based on the level of severity, the supervisor will
determine what consequences should be charged to the nurse that will therefore, not affect or
hamper the reputation and mental health of the nurse. Hence, it is established that a clinical

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supervisor is required to manage and evaluate the series of action that lead to the adverse
events.
Contribution of the second victim towards the adverse events
The second victim is the person who is considered as responsible for the clinical error
that took place, hence, no other person is best suited to highlight the series of action that lead
to the clinical error. In this case scenario, the nurse (second victim) was terminated from her
job and even her licence was cancelled, which is considered as the major drawback (Denham,
2007). The nurse could have helped the organization to understand where exactly the
organization lacked and if they required to enhance any of their equipment or modify their
treatment procedure that could have helped the organization to reduce the rate of clinical or
medical error. The second victim could have also explained the organization to highlight the
drawbacks and what the organization need to do to enhance patient and cultural safety
(Quillivan et al., 2016).

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References
Chamoun, N. R., Zeenny, R., & Mansour, H. (2016). Impact of clinical pharmacy
interventions on medication error nodes. International journal of clinical
pharmacy, 38(6), 1436-1444.
Denham, C. R. (2007). TRUST: the 5 rights of the second victim. Journal of Patient
Safety, 3(2), 107-119.
Kable, A., Kelly, B., & Adams, J. (2018). Effects of adverse events in health care on acute
care nurses in an Australian context: a qualitative study. Nursing & health
sciences, 20(2), 238-246.
Kirklin, J. K., Pagani, F. D., Kormos, R. L., Stevenson, L. W., Blume, E. D., Myers, S. L., ...
& Naftel, D. C. (2017). Eighth annual INTERMACS report: special focus on framing
the impact of adverse events. The Journal of Heart and Lung Transplantation, 36(10),
1080-1086.
Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the
US. Bmj, 353, i2139.
Quillivan, R. R., Burlison, J. D., Browne, E. K., Scott, S. D., & Hoffman, J. M. (2016).
Patient safety culture and the second victim phenomenon: connecting culture to staff
distress in nurses. The Joint Commission Journal on Quality and Patient
Safety, 42(8), 377-AP2.
Santomauro, C. M., Kalkman, C. J., & Dekker, S. W. (2014). Second victims, organizational
resilience and the role of hospital administration. Journal of Hospital
Administration, 3(5), 95-103.

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Scott S, Hirschinger L, Cox K, McCoig M, Brandt J, Hall L. (2009). The natural history of
recovery for the healthcare provider 'second victim' after adverse patient events.
Quality and Safety in Healthcare, 18:325-330
Scott, S. D., Hirschinger, L. E., & Cox, K. R. (2008). Sharing the load. Rescuing the healer
after trauma. Rn, 71(12), 38.
Sirriyeh, R., Lawton, R., Gardner, P., & Armitage, G. (2010). Coping with medical error: a
systematic review of papers to assess the effects of involvement in medical errors on
healthcare professionals' psychological well-being. Qual Saf Health Care, 19(6), e43-
e43.
Stavropoulou, C., Doherty, C., & Tosey, P. (2015). How effective are incident‐reporting
systems for improving patient safety? A systematic literature review. The Milbank
Quarterly, 93(4), 826-866.
Wu, A. W. (2000). Medical error: the second victim: the doctor who makes the mistake needs
help too.
YouTube. (2019). Sidney Dekker on The Second Victim. Retrieved 30 July 2019, from
https://www.youtube.com/watch?v=YeSvCEpg6ew