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Bula, I am Janine Bancod, I work in Lautoka Hospital as a staff nurse in

the coronary care unit. I have a total of four years’ working experience
which includes one year as an intern and three years in the unit I am
currently working in.
This write up is based on clinical governance and patient safety using
a case scenario in a form of a movie named: “Recognizing risk and
improving patient safety - Mildred’s Story”.
Firstly, clinical governance can be defined as “a system through which
national health organisations are accountable to continuously
improving the quality of their services and safeguarding high
standards of care by creating an environment in which excellence in
clinical care will flourish.” (Royal College of Nursing, n.d. ).
The video depicts an incident where an elderly woman named Mildred
who was suspected to have a second stroke. She was then sent to the
hospital to be admitted as she would not able to take care of herself
in the elderly home. It was also noted that she was allergic to wheat.
Couple of days into her admission she became better but had a history
of fall due to a slippery floor. She then attained a fracture in which she
needed to go for surgery. Post-surgery she was in a lot of discomfort
and was given co-codamol for pain relief. However, she became
unresponsive after administration of the drug which lead to her death.
This event can be defined as a sentinel event it is “an unexpected
occurrence involving death or serious physical or psychological injury,
or the risk thereof.” (Joint Commission, 2013, p. 1). This unusual
occurrence then states for an unusual occurrence report which is
attached with this write up. It can be identified that the incident type
is due to a medication error and that is Co-codamol which could have
had an adverse drug reaction with Mildred, who is allergic to wheat.
Co-codamol is stated to have traces of maize starch in its ingredients
which can be found in wheat as stated in the manufacturers leaflet.
(Zentiva, 2014).
In order, for a root-cause analysis to be done, it is important that a risk
assessment matrix is identified. The probability of this type of event
to occur would be high which is more likely than not to occur. Due to
patients receiving medications everyday as part of their daily plan. The
impact to the organization would be very high as it leads to death,
which cannot be reversed. Thus, this risk has a high probability and a
very high impact that needs to be addressed.

Root-cause analysis
During analysis, there are multiple loops holes that could have led to
the catastrophic incident. Below is a sequence of events:
1. When doctor small was giving report over the phone to the SHO,
doctor small did inform that Mildred did have an allergic reaction
to some pills containing wheat. However, SHO did not take note
of such information. The SHO was clearly distracted opening the
container of sandwich and was busy during the shift.
2. There was also improper and a lot of disturbances during
handover in the emergency department regarding Mildred’s
3. There was poor communication, understanding between Mrs
Hill, Mildreds daughter, and the ward staff, regarding Mildred’s
4. Mildred was also not supervised and there were no wall railings
for Mildred to hold on to when mobilising, causing her to fall.
5. Administration of a drug containing wheat by student nurse that
was supervised by the charge nurse who misunderstood wheat
allergie as celiac disease.

Below is a flow chart explaining each event that lead to the incident:

Communication Environment Human Factor

Improper handing over. Inadequate training
Increased stress
Poor communication levels:
between health Noise and
personnel’s and family distractions

Not involving family

members in treatment.


Poor guidelines on identifying

Not wanting to patients with allergies
wear Lack of man
identification power
bracelet Fatigue
Patient Factor Man Power
Furthermore, it could be said that the level of staffing could have
caused hospital personnel to rush resulting in improper handing over
of patients’ condition. In addition, the level of the nurses training
increases the likelihood that he/she misunderstood, the term wheat
allergy. The quality of care given was not up to par and there should
have been proper documentation of allergies and identification. For
this event, not to occur management need to set out policies and
guidelines such as standardizing all admissions i.e. having a standard
form to be filled so that all pertinent information is collected and
easily handed over. Write out a protocol that all patients with allergies
have special wrist coloured bands for easy identification.
Management need to relocated finance and resources to training
nurses regarding medications and allergies, getting more staffing to
accommodate patient ratio. Once improvements are identified
further review needs to be done so that methods established become
part of the day to day practices.
Reference list:
Joint Commission (2013). Sentinel Events (SE). Retrieved November
10th, 2016, from
Royal college of nursing (n.d.). Clinical governance: Clinical
governance covers activities that help sustain and improve high
standards of patient care. Retrieved November 10th, 2016, from
Zentiva (2014). Co-codamol 30/500 tablets. Retrieved November 10th,
2016, from https://www.medicines.org.uk/emc/medicine/22367.