PSR5101: Detailed Report on Managing Risk in the Clinical Environment

This report, prepared for the PSR5101 course on Managing Risk in the Clinical Environment, presents a reflective analysis of a clinical scenario involving an elderly patient experiencing an adverse drug event (ADE). The author utilizes Gibb's reflection cycle to explore the situation, detailing the description of the event, the feelings experienced, an evaluation of the positive and negative aspects, an analysis of what went right and wrong, a conclusion summarizing the learning, and an action plan for future improvements. The report focuses on the challenges of managing patients with dementia and the risks associated with polypharmacy in elderly individuals. It also discusses the importance of adhering to hospital policies, national safety standards, and the role of effective communication and staff training in mitigating ADE risks. The report concludes with recommendations for enhancing patient safety through improved medication management, patient screening, and family involvement.

PSR5101 MANAGING RISK
IN THE CLINICAL
ENVIRONMENT
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TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
Gibb’s reflection cycle.................................................................................................................3
CONCLUSION................................................................................................................................7
REFERENCES................................................................................................................................7

INTRODUCTION
Critical reflection refers to the effective process for finding, questioning, and analysing the
deeply assumptions about the information and knowledge one get to perceive the distinct events
and feelings (Lin and et.al (2022)). It helps in setting the goals and to begin with some strategies
to achieve it, as with this one is able to learn from the past that helps in making the efficient
decisions for future action. Reflection also termed as the reasoning process that makes the
experience a good meaning in short it develops the depth in experience that encourage the
connectivity between the course and experience. This report is going to cover my reflection by
using Gibb’s reflection cycle that will guide me to reflect over my experience, I will be using my
experience that will show the potential risk that arise on workplace. Setting is elderly patient. It
will discuss the ADE adverse drug event that harms the patient, it is the outcome of exposure to
medication.
MAIN BODY
Gibb’s reflection cycle
Gibb’s reflection model leads to explore it certain stages that covers the in depth
description about the situation that has been encountered by the individual. Its six stages are as
description, feelings, evaluation, analysis, conclusion and action plan. ADE adverse drug event
refer as the harm which is experienced by the patient, it gives the strong reaction such as
allergies, rashes, anaemia, jaundice and other severe disease which include kidney damage, nerve
injuries and also vision and hearing impairments (Villavicencio, (2019)). As mainly older people
takes more medication as their immune system is slow because of age, also decrement in kidney
and other body functions mainly cause medications to accumulate in elderly’s body at risk level.
Description: It is the initial stage of the Gibb’s cycle, it discusses what actual happened during
that situation, when it happens and its outcome. I have witnessed many situations that developed
risk situation which also covers the situation that involves the patients who are at high risk of
ADE. Situation which I encountered is 75-year-old patient who was diagnosed with dementia, he
had been placed to the level 1 nurse for their exposure to ADE. When my shift started I allocated
to this patient previous nurse have describe me the situation through ISOBAR. I read out all the
medical condition so that I can arrange preventive resource that helps me in reducing the chances
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for getting into the vulnerable situation. As I know patient is suffering from dementia and also
with ADE it worsens the whole situation, because of this patient is feeling dizzy, skin reaction
and allergies. I begin with making the care plan to help the patient for reducing the after effect of
ADE, as care plan will help in mitigating the severe risk. Because of the severe medical
condition patient was aggressively responding that is also a risk not only for me but for the other
patients as well (Vuckovic, Carlson, and Sunnqvist, (2021)). I called other staff member as well
because patient is not responding properly and I see some red bumps under his eye, which shows
reaction to medication, me and my colleague has carried out the emergency treatment that helps
the patient to feel relaxed and does not feel any irritation. I make sure to follow the hospital ADE
policy that helps me to complete all the documentations. That include the Next of kin, nursing
care plan, also completed the clinical incident management system form which is also viewed by
the medical officer.
Feelings: This Gibb’s factor helps in reflection on the feelings that was experienced during that
situation, as for me I already worked in a health care unity to help the patient for their treatment
process. In case of dealing with the patient who are at the risk of ADE is the different situation
for me, although I have taken the preventive measures to help the patient but still patient got skin
reaction because of exposure to certain medication (JENNINGS, LIRA, and INGRAM, (2021)).
I was feeling so nervous at that time because at some point I was at the risk because of the
aggressive behaviour of the patient. I have taken all immediate prevention measure to help the
patient, however I can’t have helped out the patient to not get the red bumps under the eye.
Because of this I was worried about the patient’s condition because of ADE risk my only focus
at that time was to provide the better treatment that incorporates to efficiently handle the
situation. For that, I immediately call my fellow staff to help me out in managing the case of the
patient, as he helped me to manage effectively the sudden allergic issue. I took medication that
helps in reducing the after ADE effect and it also helps in calming the patient so that he will
respond effectively. After all sudden measure I succeed to make patient relaxed and latterly red
bumps also started settled down and it prevents in managing the risk of ADE. I also feel that
what other will feel about this incident, thus I was completely succeeded in handling the
situation.
Evaluation: This stage mainly discusses the situation evaluation which covers both negative and
positive event as what things was good and bad about that certain experience. ADE is the severe

health condition which mainly found in older people. As polypharmacy is one of the medication
that consume more than the necessary clinical it is major risk factor for the ADE. Elder people
who takes more medicines and more vulnerable to the specific drug have severe health impact as
compare to the younger person (Bass and et.al (2020)). Regarding my clinical experience patient
was already suffered from ADE effect because of this patient was hospitalised for almost 3
months. There are different risk factors that linked with the ADE. I have learned about the ADE
risk as such drugs for that harm mainly outweigh the advantage such as benzodiazepine sedative
that is used for the older people. It is also clear that most of the ADE risk is caused by the
general use of medicines that have risks but it often provides benefits if it used in proper manner.
Though in my clinical experience to take care of the patient I found the risk factor which
resulting in greater exposure to ADE for patient, as patient has poor eye sights and hearing
impairment also because of dementia patient do not focus on physical activity often suffers from
the hyper tension all these cause makes him to take more medicines that lead them to face ADE
risk (Pangh and et.al (2019). Although there was no proper arrangement in the organisation to
prevent ADE risk at immediate level which is also a barrier for the better treatment. Although
now organisation have taken all measures and follows the national safety and quality health
service standards (NSQHS) to prevent such ADE risk and to ensure to provide better treatment
plan to patient.
Analysis: It covers the situation analysis as what went right and how one can respond in different
manner to tackle the situation. As for me to handling the patient with ADE risk exposure, I found
that current policy regarding ADE is efficient in providing the better result which is also meeting
the NSQHS policies and standards. As there are some strategies which the institute for the safe
and secure medication can look into as to first maintain the list for the drugs which are mainly at
high alert as such medication can cause major harm to the patient if do not used properly (Lin
and et.al (2021)). As maintaining the list helps in treatment process as it is analysed that some of
the medicines looks alike and have the similar name but have the distinct pharmaceutical
properties. Thus making out the list will help in taking the suitable medication for which the
patient is not exposure to any kind of risks. Also other measure can be taken out is to screen and
assess the patient so it helps in preventing the risk of adverse drug event, for better lay out of the
treatment it is important to engage the family members in care plan. Also to efficiently respond
to the patient who are at high risk of experiencing the adverse event. As other preventive
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measures can also be taken out to reduce the likelihood of such risk which is for the clinician to
must choose the appropriate medicines in certain amount of dose, frequency. Also it is important
for the prescriber to read out the details as some medicines looks similar but have the different
properties. As we can put all the strategies in together to follow so it will help in reducing the
ADE risk and also strategies will help in laying out the emergency or immediate treatment.
Conclusion: It generally discuss in summarise form as what have learnt from such situation and
what can be done better in future event. In my case for Mitigating the ADE risk factor for the
patient was dangerous event for me as I got very nervous when patient got sudden allergic issue
also he was not responding properly that also cause the risk situation for me as well. I learned
many things which will help me to efficiently manage the situation in future (Austin, Gilkison
and Clemons, (2020)). As for handling that patient at that time I follow all the prevention
strategies and treatment plan to support the patient with better care, also organisation have put
more focus on this factor to mitigate it immediately. Pharmacist are told to screen the patient
before starting the treatment as it helps in analysing the facts that suggests that particular patient
is allergic to certain drugs and medicines. And also to involve the patient’s family members in it
that will help in making patient responding to the certain treatment plan. As for me better
knowledge regarding ADE can be useful in order to handle that situation overall skills and
practice ar4e required to implement certain strategies.
Action Plan: This plan mainly sums up the things which the one can required in order to
improvise next time. It is the last stage of Gibb’s reflective cycle that entails to lay out the
specific action plan that is based on learning the knowledge from experience so it can be used for
future activities (Snowdon, (2018)). As for my experience regarding ADE risk identification and
mitigation for thee patient, I learn that knowledge about medicines is also important and before
begin with it is also important to lay out the screening for the patient first. Further follow of the
standards, rules and regulations helped me a lot to handle the situation. I will proceed to learn in
depth knowledge about the ADE factor so that in future I will prepare with all mitigation factors
that will be implemented immediately so that patient can’t get any allergic issue. It is also
important for me to have the better and effective communication skills which will guide me to
interact with the patient and enable them to efficiently respond over the treatment. For the
workplace it is essential to have strategies for timely conduct the training session for the staff to
increase their knowledge and to efficiently practices all the strategies that is suggested by the

NSQHS in order to prevent any risk for the patient’s health (Nuuyoma and Ashipala, (2018)).
Thus it will guide in earlier risk identification so that mitigation strategies can be prepared.
CONCLUSION
From the above it is concluded that reflection helps a lot in practicing the best in future
events. Above, it illustrated that ADE is severe risk that gives bad effect over the health as
mainly older people who takes more drugs are at high risk of ADE. I overall concluded
organisation have better and efficient policies for managing the ADE risk which helps a lot in
treatment for the patient. Throughout Gibb’s element it discusses the overall situation as how
risk is identified and mitigated with some strategies. I can say that organisation also required to
follow all the ADE mitigation strategies in order to prevent and reduce the chances of this risk
also to train the staff also be beneficial to suggests the right medication which the patient is not at
risk of ADE.
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REFERENCES
Books and journals
Austin, D., Gilkison, A., & Clemons, J. (2020). Turning reflection into learning: a practice
development tool for midwifery students. Reflective Practice, 21(3), 301-315.
Bass, J. and et.al (2020). Midwifery students’ experiences and expectations of using a model of
holistic reflection. Women and Birth. 33(4). 383-392.
JENNINGS, C., LIRA, M. T., & INGRAM, S. (2021). 3 Key considerations for continuing
professional. ESC Textbook of Cardiovascular Nursing. 55.
Lin, C. and et.al (2022). Exploring the experience of reflective writing among Taiwanese
undergraduate nursing students: A qualitative study. Journal of Professional Nursing. 40.
105-110.
Lin, C. C. and et.al (2021). Enhancing reflection on medical and surgical nursing among nursing
students: A participatory action research study. Nurse Education Today. 102. 104935.
Nuuyoma, V., & Ashipala, D. O. (2018). Second year nursing students’ experiences of clinical
placement in a rural health centre. International Journal of Studies in Nursing. 3(2). 107.
Pangh, B. and et.al (2019). The effect of reflection on nurse-patient communication skills in
emergency medical centers. Journal of caring sciences. 8(2). 75.
Snowdon, K. (2018). Humour in reflective practice. Journal of Paramedic Practice. 10(4). 144-
146.
Villavicencio, V. V. (2019). Reflective Practice: Exploring Counseling Interns’ Reflection in
Nonprofit Community Mental Health Setting (Doctoral dissertation, Northeastern
University).
Vuckovic, V., Carlson, E., & Sunnqvist, C. (2021). ‘Working as a Real Nurse’: Nursing
Students’ Experiences of a Clinical Education Ward in Psychiatric Care. Issues in Mental
Health Nursing. 42(11). 1038-1047.