Healthcare Case Scenario


Over the years, the health sector has faced multifaceted changes mainly due to transformations in the social and environmental institutions. For this reason, the health needs of the people have drastically changed, and therefore more focus and attention directed towards the same. It is essential to promote efficient and sufficient governance at any clinical institution as this determines the quality of lives of individuals. Equally, it is worth noting that all activities and operations within the clinical setting have direct implications to the health and general well being of the stakeholders. Over the years, there have been guidelines and standards that are set by renowned clinical institutions that assist clinical specialists and professionals in managing the patients. In general, these standards ensure a clear line and explanation is placed on how patient care is to be carried out, and that factors that could hinder its effectiveness. According to the Annual Report on “sentinel and serious untoward events of 2018, it is evident that proper auditing and documentation in the entire healthcare service delivery is paramount. This not only promotes a ‘good communication channel but also has a sustainably healthy population and total quality management (TQM). This paper therefore, gives deep insight on of a case scenario in which a ward nurse leaves a patient halfway attended to and the implications that followed and how this could have been prevented in regards to the Ishikawa’s Fishbone diagram.


As previously mentioned in the introductory part, clinical governance and management is a paramount tool in any medical care facility or institution.  Just like in any other environment, mistakes are bound to happen in the medical care environment, only that it have more negative implications here. Such mistakes in the medical environment are commonly due to improper auditing, lack of sufficient training of the caregivers, poor communication channels, unconducive environment, to mention a few. Such causes are things that can be controlled and changed to the better functioning of healthcare service delivery. It is also important to note the fact that such mistakes I the health care institutions and facilities occur either during assessment, diagnosis, prescription, medication, treatment or during aftercare. All these steps of procedure are equally important as they individually contribute to the health and general well being of the individuals. In the same line of thought, it is crucial to pay attention to the effects of poor clinical governance and management. As previously stated, a lack of a proper documentation and auditing system is the leading factor resulting in medical mistakes in healthcare or clinical environments. Therefore, all the medical caregivers have the responsibility to ensure that the entire clinical environment promotes high-quality health care delivery, as this will directly replicate to a healthy community.

Equally, effective clinical governance directly and fosters primary health organizations and thus improve the teams teamwork, support the entire clinical and non-clinical staff, meet the set standards and requirements and most crucially improve the health outcomes for the respective populations. It is also important to appreciate the fact that the different forms and manifestations of clinical governance acts as supportive or building blocks for the health sector in any population. In other words, proper clinical management dictates the general well being and health of the people as well as their quality of life. With this in mind, it is therefore evident that much focus and attention should be put towards the same, in a bid to not only improve the healthcare of the respective populations but also empower the medical caregivers in their respective roles. By so doing, a more sustainable health system will be developed.



Also referred to as the root cause analysis diagram, the Ishikawa’s diagram helps in pinpointing and identifying underlying factors and causes of events in a specific institution or facility. In most cases,  this diagram has been used to promote a sense of brainstorming that in turn helps in the identification of the root causes of an adverse event, as well as prioritizing the same. In other words, this diagram is more of a visual method of looking at causes and effects. For many years, the Ishikawa’s Fishbone diagram has been used as an effective brainstorming  tool that has helped in the identification of objects of some cases and given appropriate ideas to address the same. Another important factor worth appreciating regarding the diagram is that it promotes a sense of teamwork among members of an institution as it brings them together to brainstorm on the possible root causes of an adverse event. Equally, Ishakawa’s Fishbone diagram. The Ishakawa’s Fishbone diagram is used in instances such as; When identifying the possible root causes, fundamental reasons for a condition, When sorting out and relating some form of interactions among factors that affect a specific process, and when analyzing existing problems so that corrective actions can be put in place.

As previously mentioned, the Ishikawa’s Fishbone diagram is a useful tool in the identification and organization of known or suspected causes of quality events as well as those of low quality. The basic formula utilized by the diagram helps respective stakeholders to think and reason out more systematically. For this reason, it is important to note that the Ishikawa’s Fishbone diagram has its fair share of benefits. First, the diagram helps in the determination of the root causes or cause problems as well as quality characteristics using a more structured strategy. Secondly, it promotes group interaction and participation as it optimizes the knowledge of the whole team. Thirdly, the diagram utilizes an orderly and easy to read format to bring more insight into the relationships that exist between the causes and effects. Fourth, the diagram indicates the possible causes of differentiation and variation in a process. Fifth, it increases knowledge and insight into the whole process under question by assisting all to get to learn even more on the different factors and how they relate to each other. Last but not least, this diagram helps in the identification of areas where data should be gathered collectively, to promote further study.

On the other hand, the diagram has its weaknesses which are equally worth looking into. Such weaknesses portrayed by the Ishikawa’s Fishbone diagram might affect the overall outcome of the study, and therefore poor investigation. First, the process of group brainstorming might produce causes that might be potentially irrelevant. This will result in an enormous waste of time and resources to the respective team. Secondly, the insights developed from the diagram are mostly based on opinions, rather than scientific facts. Thirdly, for massive and complex case scenarios, a large space id needed to develop the diagram. Last but not least, the complicated interrelationships of multiple factors are quite difficult to show on the Ishakawa’s Fishbone diagram.


Case Scenario

Looking at the case scenario, a ward nurse is seen administering or taking care of a patient just like on an average day. Keep in mind that this was a bustling environment with noises and movements that were quite uncontrollable. This nurse is further witnessed taking a drug into a syringe but does not proceed to administer it to the respective patient as she was interrupted along the way. She then leaves the drug on the table and delegates the duty to her fellow ward nurse who was nearby. The major mistake that she did is that she did not adequately communicate the details of the prescription after delegating her duty to her fellow nurse. What followed was that the second nurse administered the drug to the wrong patient. The prescribed medication resulted in a fatal case. The second nurse asked a different patient if those were his drugs, to which the patient replied ‘yes, I always have yellow tablets.’ This was in fact the wrong patient. What followed was the incorrect patient being given the medication (oral morphine). This patient suffered from respiratory problems, as the drug promoted a respiratory arrest and the patient succumbed to death. This is a perfect scenario in which the Ishakawa’s Fishbone diagram can be adapted to help in determining the root cause of this fatal event. Through the description, we will be able to point out possible root causes of this event, and also have a clue on important strategies that could be used to prevent the same from happening in the future.



Based on the above diagram, it is clear that the possible root causes of this fatal event are based on the procedure used, the place (ward environment), and the employees (ward nurses). These three main factors are responsible for the occurrence of this fatal event, that claimed the life of an innocent patient. In this section, all the three causes as illustrated in the Ishakawa’s diagram above will be broken down, and more insight developed from the same.

To begin with, we look at the place as a contributing cause of this event. As previously mentioned in the case scenario explanation, the environment during when the incident occurred was very noisy and busy. In a standard clinical setting, the general environment should be as conducive as possible. This means that there should be utmost calmness and not noise and general confusion. In this case, we witness a very busy ward with people walking in and out of place without any proper plan or arrangement. Besides, there was plenty of noise in the department, making communication and concentration quite hard. This two aspects of the environment could have been a possible cause of the fatal accident. First, had there been a proper movement strategy within the ward, the first nurse could have concentrated and finished with her patient, rather than delegating her role to the other nurse. Secondly, the noisy environment hindered efficient communication not only between the nurses but also between the second nurse and the respective patient. This event could have been avoided, had the clinical management team maintained a peaceful and well-organized environment at the ward. In other words, a more peaceful and organized place could have smoothened the operational flow of activities at the specific neighborhood.

Secondly, the people involved in this case scenario played a considerable role in promoting the occurrence of this event. The two main aspects surrounding the people factor are lack of knowledge and poor communication. To begin with, the patient himself lacked proper experience on the type of medicine he was taking at the moment. When asked by the second nurse, the patient just said that he takes yellow pills. Had he had better knowledge of the specific medication he was currently being administered with, and the fatal accident could have been avoided. Also, the nurses lacked sufficient understanding of how they do complete drug administration, as well as how to delegate tasks in the clinical setting. The first nurse put the drug in the syringe but did not adequately inform the second nurse what kind of medicine it was, and to which patient it was meant for. The first nurse had the responsibility to fully tell the second nurse about the patients’ conditions, what kind of medications each was having, in what doses, and also any other crucial information that could have been of value to the service delivery. This case scenario proves that there was poor communication between the respective stakeholders in this event. In an ideal clinical environment, the nurses and patients should have a well-established communication channel that ensures service delivery is done at the best modes possible.

Thirdly, the procedure used during the whole process was quite questionable. First, The patient himself only knew he gets administered with yellow tablets, but he did not know the name of it. Equally, the drug (material) was already open and therefore giving even more room for assumptions both by the second nurse and the patient. In an ideal clinical setup, the procedure of drug administration is well organized and documented to prevent cases of confusion and misprescription. In this case, there was insufficient documentation, thus hindering appropriate service delivery. Secondly, the procedure used in task delegation was not up to standard. In an ideal clinical environment, the commission of the tasks has to be orderly, and both parties fully informed of what is expected to them. However, in this case, the first ward nurse left without doing any of the above. For this reason, the procedure used can be a root cause for the occurrence of the fatal event that resulted in the death of the patient.

According to Lewin’s force field analysis, there exists driving and opposing forces that contribute to the occurrence of an event. In our case scenario, there equally exists driving and resisting forces that played a part in the appearance of the fatal incident. The two main driving and resistant factors in question are provisions of quality and timely care, and a lack of knowledge respectively. It is essential to appreciate the fact that these two factors have a massive effect on the general provision of quality healthcare to the people. Over the years, the Lewin’s force field analysis diagram has been used to promote total quality management and generally boost sustainable health care provision. In this case, the clinical ward nurses can optimize their need to provide quality health care to their patients by addressing the real resisting factor. That is the lack of knowledge, not only among them but also among their patients. By sending the two driving and resistant elements, there will be improved health care delivery, as well as an empowered group of nurses and patients.

The best clinical governance strategies that could be used in preventing such mistakes in this clinical setting are; proper education and training of the employees, integrated care pathways, and research-based practices and clinical effectiveness. First, adequate education to the nurses and patients is paramount, mainly because an informed institution is usually at a better position to make well-informed decisions and strategies. In this case, the nurses should be well trained on how to handle clinical practices, from the diagnosis, treatment, medication, and aftercare. This will ensure their full empowerment to perform all these stages of service delivery in the best ways possible. Equally, the patients should also be educated and trained on the types of medication they receive, as well as the clinical operations during their stay at the medical facility. In other words, a group that is well informed stands at a better position to make wise decisions. Secondly, the adoption of integrated healthcare methods to the clinical setting can also be of great relevance, especially in such a busy environment. By mixed healthcare methods, it means that different operations within the medical set up have individually been fully met through departments and sections. In such a case, drug prescription could be digitized to avoid confusions and accidents. For instance, had there been a well-structured drug administration mechanism with a photo and name of the specific patient, the second ward nurse would not have given the drug to the wrong patient. Thirdly, the utilization of research-based practices in the clinical set up could be a relevant strategy in improving service delivery. Over the years, research has proven to be of good value in addition to almost every sector of our society. In such a case, research can point out gaps that have existed before and how they could be addressed to avoid the mistakes from happening again.

Last but not least, clinical effectiveness is paramount in ensuring such errors do not occur. Effectiveness cuts across the entire clinical operations and thus should be paid much attention and focus to. In this case, the clinical management should ensure effectiveness is promoted in regards to the environment, nurse-patient interaction, and clinical governance at large.

In the last couple of years, medical institutions have adopted SMART standards in their day to day operations. The SMART rules are a set of scientific and technological tools that help in promoting better health care service provision. Not only has SMART strategies been utilized in the healthcare sector, but almost every industry in our society today. It does not go unappreciated that technological and scientific tools have been of great use and relevance in promoting sustainable healthcare globally. In this case, SMART standards or technological tools could be utilized to prevent the fatal accident from happening. These include; a digitized drug administration portal, an electronic communication system at the clinic, to mention a few. Such SMART strategies could be of great relevance and mainly would prevent this fatal mistake from happening at the clinic.


The fundamental causes of this fatal case scenario are an unconducive environment, lack of knowledge from the employees, as well as poor accountability. Better clinical practices that involve full responsibility and liability would have helped in preventing the death of the patient through wrongful prescription. The two main driving and resistant factors in question are provisions of quality and timely care, and a lack of knowledge respectively. These two factors are the underlying ones that should be prioritized by the whole team to promote efficiency and effectiveness in the future. In the future, all healthcare providers ought to be adequately trained on how to handle clinical processes for there to be sustainable health among the people. The best clinical governance strategies that could be used in preventing such mistakes in this clinical setting are; proper education and training of the employees, integrated care pathways, and research-based practices and clinical effectiveness. Besides, the adoption and utilization of SMART standards in the whole clinical processes would significantly reduce the chances of such confusions and mistakes from actually happening. Examples of possible SMART measures suitable for this scenario are digitized drug administration portal and an electronic communication system at the clinic.


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