SNPG927 Promoting Clinical Excellence

Table of Contents


Recall your experience as a health-care professional.

Compare your experience in a current or previous workplace to current literature on the design of health services.

You should be specific about the following:

How clinical governance principles can be applied to improve health care system

As a member of the individual staff, your role is to ensure quality and safety in healthcare.

How to empower patients to be more involved in their healthcare experience


It is essential to follow certain principles and protocols in today’s healthcare industry to ensure the best service delivery to healthcare recipients.

It is crucial to ensure patient wellbeing and quick recovery.

A case study from a literature can be used to gain more insight into the topic of quality and safety in healthcare.

Gluyas (2014) and Morrison (2014) have described an incident that involved the death of a resident at a nursing home, as well as the medication errors that led to the death.

This article gave a glimpse into cognitive functioning, which is the ability to think and process information.

The resident’s death was caused by the disease itself and not any individual.

On closer inspection, however, it was discovered that the resident’s attending nurse was responsible for administering 25mg of morphine subcutaneously instead of 2.5mg.

It is vital that the clinical sector has a clear framework to analyze patient safety and care contexts.

To facilitate the recognition of patient safety issues in a timely manner using root cause analysis, the London Protocol was established (Ahmed and al.

The London Protocol posits that clinical practice which might cause an incident may in turn be influenced by other factors.

These factors could include task and technology factors as well as individual and team factors. They also might influence organizational and management factors.

The given case highlights the importance of individual, team, and work environment factors.

Although the nurse who administered the wrong dose of subcutaneous morphine may have been the cause of the incident, the criticality of the underlying illness and the patient factor could also be a contributing factor to the death.

According to reports, the nurse was a recently graduated nurse and was doing her job as a registered nurse on that shift. She was also working with three other extended care assistants.

Although the nursing assistants kept reminding the nurse about the need to administer the prescribed morphine medication on time, the nurses felt that they were not seeing the situation well. The nurse also asked the nurse who was present while she administered the medication to verify the dosage.

The influence of nursing burnout and work load can often lead to poor quality work (Van Bogaertet & Co.

The incident was caused by the team factor.

The incident was also caused by confusion with morphine administration and the absence of an orientation course for new staff at the nursing home. Additionally, the increased workload from the large number of patients and the need to collaborate with other healthcare professionals outside the organization created chaos and added pressure on the nursing professional.

In this instance, the problem was caused by the new registered nurse’s work environment.

The patient’s experience of receiving the wrong medication dosage as seen on the second spot while administering it may have been caused by multiple factors.

The modern healthcare sector is looking for a concept called clinical governance. It focuses on optimizing healthcare delivery.

Clinical governance is about improving the effectiveness and efficiency of healthcare delivery. This can be achieved by removing or restricting unsafe practices, or those that have little benefit.

Participation of the consumer is an integral part of this process.

This measure is a step in the right direction to ensure that resource allocation can be sustained by properly taking into account consumer preferences and views.

Relevant literature has shown that consumers are increasingly participating in public-funded health services. This is documented in standards as well as policies.

The resource allocation process was primarily geared towards communication, consultation, and participation in improving the delivery of healthcare services for those who are eligible.

In clinical governance, consumer values and perspectives are becoming more prominent to include them in crucial decision-making (Harris et. al.

Potential service users are patients.

Understanding and support from patients can help improve the safety and quality of the service they receive.

This issue was raised and is now part of public health policy to ensure that the best healthcare services are provided to patients.

The data obtained from health services takes into consideration the preferences and values of patients so that healthcare service delivery can be improved (Hripcsak, et al.

The principle of consumer participation is not valid in this context. There is no evidence that the patients’ preferences and opinions were taken into account when forming the care plan.

A medication error was also identified as a possible factor in the death of a resident at a nursing home.

The case study does not mention negligence of duty by nurses in not complying with the wishes of patients. This may lead us to conclude that consumers were not involved.

In order to provide the best care possible for patients in need, clinical effectiveness is another important component.

Healthcare professionals and healthcare providers must make greater efforts to improve the quality of their clinical care.

The concept of clinical governance is a way to create safe, effective and responsive services.

The healthcare delivery system is still centered on the commissioning of high quality care services. Evidence-based practice has been highlighted to inform healthcare workers about the best ways to improve the service’s efficacy (Hamer & Collinson 2014).

Relevant research also emphasized the importance of providing safe and high-quality healthcare services through continuous research and innovation.

This is possible through a coordinated, integrated and continuous healthcare delivery (Jones & Killion 2017).

The scenario presented shows that clinical effectiveness could have improved and been well addressed if there had been a provision for a simulation-based strategy to implement in the educational and clinical sectors.

These procedures can be used to reduce errors arising from knowledge-based or rule-based reasoning.

A better workforce in the clinical healthcare team may allow for better outcomes when it comes to providing adequate healthcare services to patients.

To achieve optimal outcomes, modern interdisciplinary approaches to clinical care are increasingly being promoted.

Collaboration with healthcare workers is key to the management of clinical standards in an efficient manner. (Kennedy and al.

The clinical environment must be supportive of the learning of evidence-based practices principles.

McKeever and colleagues suggested that clinicians, nurses, and inter-professional students play a crucial role in maintaining a workforce that is efficient so that clinical outcomes can be greatly improved.

The emergence of medication error was also caused by the absence of nursing staff support.

The lack of orientation for new staff members in this setting also contributed to medication error.

Perhaps the coalition, unity, and sufficient professional knowledge and training amongst registered nurses and attending nurse might have been able to help in some way.

Another aspect of clinical governance is risk management. It ensures that patients receive the best care possible without posing any dangers or harms to their bodies.

Both governance and management roles are crucial in ensuring that the risk assessment is done correctly and any subsequent tasks are completed (Brennan & Flynn 2014).

Training healthcare staff, who are directly responsible for providing healthcare services to patients depending on their needs and circumstances, can help advocate patient safety culture (Sendlhofer and al.

The lack of proper training and orientation for newly appointed registered nurses to increase familiarity with the immediate environment may have prevented the potential risk associated with medication administration.

Promoting clinical excellence is directly tied to the interaction of many factors, such as the principles of consumer participation and clinical effectiveness.

Each of these factors must be emphasized in order to provide quality and safety healthcare services to patients.

Refer to

Ahmed, M.; Arora, S.; Tiew, S.; Hayden, J.; Sevdalis. N., Vincent. C. and Baker. P.

The Lessons Learnt patient safety program is a foundation for a safer future.

BMJ Qual Saf 23(1), pp.78-8.

Brennan, N.M., and Flynn M.A. (2013)

Clinical governance, clinical management, and clinical practice are differentiators.

Clinical Governance: An International Journal 18(2), pp.114–131.

Gluyas (H.) and Morrison (P.), 2014.

A case study on human factors and medication errors.

Nursing Standard, 29(15), pages 37-42.

Hamer, S., and Collinson G., 2014.

The Handbook for Practitioners: Achieving Evidence-Based Practice Ebook

Harris, C. Harris, Ko, H. Waller, C. Sloss, P., Williams, P.

Sustainability in Health Care by Allocating Resources Effectively (SHARE4) 4: Exploring possibilities and methods for consumers to engage in resource allocation in a local health care setting.

BMC Health Services Research, 17(1), P.329.

2014, Keenan, G.M.

A report from the 2012 AMIA Health Policy Meeting.

Journal of the American Medical Informatics Association 21(2), pp.204–211.

Jones, A., and Killion S., 2017. Title Clinical governance for Primary Health Networks.

Keers, R.N. Williams, S.D. Cooke, J. and Ashcroft D.M. (2013).

A systematic review of observational data to determine the prevalence and nature of medication administration mistakes in health care settings.

Annals of Pharmacotherapy 47(2), pp.237-238.

Kennedy, M. Elcock, M. Ellis, D., and Tall, G.

Pre-hospital and retrieval medicine. Clinical governance and workforce models.

McKeever, S.; Twomey (B.), Hawley (M.), Lima (S.), Kinney (S.) and Newall, F. (2016)

A Nursing Clinical Effectiveness Committee is established to engage a nursing workforce in Evidence-Based Practice.

Worldviews on Evidence-Based Nursing, 13(1), pages 85-88.

Sendlhofer G.; Brunner G.; Tax, C.; Falzberger G.; Smolle J., Leitgeb K., Kober B. and Kamolz L.P. (2015)

The impact of risk managers on the systematic implementation of clinical risks management in large university hospitals.

Nurse unit teams matter: The impact of nurse practice environments at the unit level, nurse work characteristics and burnout on nurses’ job outcomes, quality of care and adverse events–A cross sectional study.

International journal of Nursing Studies, 51(8), 1123-1134.

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