CNA344 - Clinical Reasoning: Analysis, Errors, & Reflection

This assignment provides a critical analysis of clinical reasoning errors in a nursing context, focusing on a 52-year-old female patient undergoing a laparoscopic cholecystectomy. The author identifies two primary clinical reasoning errors: ascertainment bias and premature closure, stemming from missed history taking and overlooking alternative explanations for the patient's post-operative condition (light-headedness, shivering, and wound oozing). The report discusses the potential impacts of these errors on patient outcomes, such as misdiagnosis and delayed treatment, and emphasizes the importance of considering various factors like medication side effects, pre-existing conditions, and post-operative complications. Ultimately, the author reflects on strategies for improving future practice, including continuous professional development, seeking second opinions, and promoting patient involvement in decision-making, aiming to reduce cognitive biases and enhance the quality of care. Desklib offers similar solved assignments and resources for nursing students.

Running head: NURSING
NURSING
Name of the Student
Name of the university
Author’s note

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Introduction
Clinical reasoning cycle is an important part of nursing for proving a patient centered
care due to the fact the process is dependent on the knowledge and the intuition for influencing
the decision making for the circumstances of the individual clients (Australian Learning and
teaching cycle. 2018). The experience and the knowledge of the health care professional is an
extremely important step in the consolidation of the clinical reasoning (Saposnik et al. 2016).
Medical errors are common in 1.7-6.5 % of all the hospital admissions causing about 100,000
unnecessary deaths per year. The medical errors lead to unnecessary medical costs (Saposnik et
al. 2016). Most of the errors in the clinical reasoning is because of the inadequate knowledge or
incompetence but to frailty of the human perception under the conditions of complexity. Half of
the involved errors are because of the reasoning or decision quality. Such clinical errors are
highly preventable and can be easily avoided (Norman et al. 2016). In most of the cases, clinical
reasoning error occurs at the time of history taking and clinical examination. Clinicians are found
to use these data subconsciously for framing or contextualising the problem of the patient. The
patient of concern is a 52 years old female patient, who had been referred to a laparoscopic
cholecystectomy, removal of the gall bladder. On admission she was given Pregabalin 150 as the
premedication. At the time of the procedure the patient had become hypotensive and the heart
rate of the patient was also found to be higher. Being a nurse I had missed to obtain records the
history of the patient (Norman et al. 2016). The patient complained of light headedness,
dizziness and the dressings on the wounds were oozed. The patient was shivering when she came
back from the theatre. Hence the two clinical encounter that I had perceived are- I had missed the
history taking and had forgot to note that the patient was shivering and I had failed to consider

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the alternative reasons for the clinical conditions. The two clinical reasoning error types that
have been identified in this clinical procedure are- the ascertainment bias and premature
closure. This assignment would critically analyse as for why did the clinical reasoning error took
place and what the outcomes that it brought to the patient. Finally, the assignment would
conclude with a self-reflection to improve my future learning practice, such that such mistakes
does not occur in my professional career
Discussion
Premature closure is type of cognitive error in which a physician fails to consider the
reasonable alternatives after the intimal diagnosis. It can be considered to be one of the cause of
delayed diagnosis and misdiagnosis due to a faulty clinical decision making process. Clinical
decision making in emergency circumstances might manifest either heuristic thought drawing on
the clinical experience and knowledge. It is evident from the case study that the patient
complained about dizziness or light-headedness (Jones et al. 2013). Light-headedness and
dizziness can be due to the hypovolemic shock due to fluid loss from dehydration, but there are
several other reasons for the dizziness and light headedness. Dizziness or light-headedness can
occur as side effects after ambulatory care anaesthesia. It has also been stated that low blood
pressure in the patient is due to the prolonged fasting. It should be mentioned that low blood
pressure is also one of the symptom of septic shock, which is a life threatening condition of
bacterial infection. As per the cues collected it is evident that the patient might have incurred
dehydration after the surgery. Dehydration might facilitate the occurrence of septic shock. Hence
it is necessary to assess the conditions before coming to any kind of conclusions. Again, as
evident from the case study and the clinical cues, it is understood that the patient had been
administered with Pregabalin as the premedication. Dizziness or light-headedness is one of the

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key side effects of pregabalin. Hence, side effects of the medicines should not be rules out.
According to missed-diagnoses are difficult to determine, but might be different from the reality
of the person’s medical condition. The missed and the misdiagnoses are reported rarely as there
are no real mechanism for reporting them. If the patient dies, that family might request an
autopsy, but the autopsies can be expensive unless the information can be put to any good use
and might not be recommended by the professionals (Nendaz and Perrier 2012).
While I was reviewing the current medical status of the patient, I missed to take notes on
the medical history of the patient. According to Bickley and Szilagyi, (2012), the purpose of
getting patient history is to receive the subjective data from the patient or the family of the
patient, such that the health care ream and the experts are able to create a plan collaboratively for
promoting health, addressing the acute health care problems and minimising the chronic health
care problems. Throughout the report, there were no such instances of history taking. The patient
might have chronic conditions like diabetes. It should be mentioned, that dizziness is a common
problem with the people suffering from the diabetes. Again, I had also overlooked the
possibilities of the migraine on the right side of her brain. Migraine pain can indicate towards
stress and anxiety. The patient might be anxious or stressed for the surgery, but cognitive errors
like premature closure might compel a clinician to interpret wrong cues. Headaches are common
after the surgery as there is an increased swelling or pressure on the nerves, that sends pain
signals to the brain and hence headache is common after a surgery.
The ascertainment bias is designed by prior assumptions or misconceptions,
expectations. It is one of the cognitive errors (Jones et al. 2013).The patient was shivering while
she was brought to the department. It should be mentioned that postanesthesia shaking can be
one of the common complication. According to Saposnik et al. (2016) the cognitive biases and

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the personality traits can lead to diagnostic inaccuracies and medical errors causing inadequate
utilisation of the resources. It is evident from the case study that the blood pressure of the patient
is low and I had commented on an estimation that the low blood pressure and high heart rate
might be because of prolonged fasting before the surgery. But several other complications in the
post-surgical period should not be ruled out. Tachycardia after surgery can be dangerous and the
can be because of some underlying physical conditions. Failure to collect all the relevant cues in
establishing a differential diagnosis results in significant possibilities being missed. Failure to
receive the cues throughout the treatment regimen might lead to clinical error. According to
Bogdanic et al. (2013) surgical site infections are the most common type of the health care
associated infections. The incidence of the surgical site infection in laparoscopic
cholecystectomy is common. Oozing of the surgical site signifies excess formation of wound
exudates. Reddy et al. (2012) have stated, that heavily exudated wounds might indicate towards
heavy burden or the chronicity of a subclinical infection. It should be kept in mind that purulent
exudate is not normal and can be associated with high bacterial levels. Hence, failure to collect
proper cues and missed diagnoses thus can lead to medical errors.
Conclusions
I believe that there are several intervention strategies that can be followed for an
improved decision making. I would participate in training and professional development
programs that would expand my clinical expertise, always seek for the second opinion or discuss
things with my peers, without the fear of being ridiculed (Graber et al. 2016). Furthermore, I
believe that educational outreach by the respected and seasoned peers also helps in the decision

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making process. I would polish my knowledge about the handover and the information system
providing seamless transmission of the clinical reasoning from one patient by the use of both
didactic and experiential teaching. I would focus more on the feedbacks in the form of clinical
audits, both to ensure a safe care to the patient, and also to develop my professional standard. I
should not be overconfident of my skills and should not be affected by any predetermined
notions (Singh et al. 2016). I believe that at the level of individual health experts, maintaining a
continuity of care for a long term facilitates awareness from past mistakes that take time to rise. I
intend to research more in order to have an improved understanding of the error theories and the
skills required in meta-cognition. (Mamede et al. 2015) have stated that slower and more
methodical problem solving reduces errors. In order to develop professionally, it is important to
critique my own understanding in cases where errors are more likely to occur. I have to remain
more alert, and vigilant of my own thinking. This will help to activate my though processes to
make decisions with less bias or errors. While collecting patient cues I should be mindful about
each and every steps of the Levett Jones clinical reasoning cycle, such that I do not miss the
important cues (Mamede et al. 2014). Finally, I believe, that the patients, carers and the families
should be encouraged to improve the quality of the decision by being mindful of the
circumstances pertaining to themselves or to the ambience, that might increase the chance of a
clinical error (busy emergency department) for participating in the decision making process and
raise the flag if they find any incident of error.

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References
Australian Learning and teaching cycle. 2018. Clinical-Reasoning-Instructor. Access date:
25.1.2019. Retrieved form: http://www.utas.edu.au
Bickley, L. and Szilagyi, P.G., 2012. Bates' guide to physical examination and history-taking.
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Bogdanic, B., Bosnjak, Z., Budimir, A., Augustin, G., Milosevic, M., Plecko, V., Kalenic, S.,
Fiolic, Z. and Vanek, M., 2013. Surveillance of surgical site infection after
cholecystectomy using the hospital in Europe link for infection control through
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Graber, M.L., Kissam, S., Payne, V.L., Meyer, A.N., Sorensen, A., Lenfestey, N., Tant, E.,
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