• Internal Code :
  • Subject Code : NUR30004
  • University : Swinburne University of Technology
  • Subject Name : Nursing

Case Study: Gabrielle Thompson

Sources of Errors

The underpinnings of continuous improvements and quality of care underpin clinical governance, an essential part of the vision of trust, processes for delivery in services and systems (Donaldson, 2018). Hence, clinical governance should also influence system design specifications, as postulated by Panteghini & Rogers (2019). The paper will provide insightful information on the identification of the sources of errors and how measures can be taken to prevent these clinical errors. Additionally, the paper looks into the process of measuring the effectiveness of the errors mentioned above.

There is a lack of job specifications and specialisation. When Gabrielle came in at the beginning of the shift, the safety standards had not been checked, and she thought it was part of her work. She was too busy to conduct the necessary safety checks. Additionally, there were no gloves in the room and therefore presumed safety while performing the procedure. In this regard, Gabrielle was guilty by the fact that she ignored protocol, thereby rendering both of them unsafe. Registered nurses are regulated practitioners such that they are held responsible for their actions. Moreover, although Gabrielle identified that one of the safety factors was not met, there were no interlink devices, but Gabrielle failed to report this.

Lack of necessary skills and knowledge regarding the protocol used in the treatment of needle stick injuries was in play. Although Gabrielle had acquired the essential skills, knowledge, and abilities, the incident happened too soon, and she was too anxious to remember what she was shown during ward orientation. The nurse had only been provided with orientation-level educational experience; therefore, she could not carry out the task effectively.

Poor clinical incident reporting mechanism was put in place for preventing these kinds of clinical problems. After Gabrielle had undergone the ordeal, she was hesitant to let her boss know because she thought that she would be labelled as an incompetent and unsafe nurse. Clinical leaders should ensure that there is a working environment that is free of reprimanding errors so that they can be identified and dealt with in the future.

Poor emergency management response framework leads to overwhelming resource stress. Gabrielle could not have gone to the emergency department, given she would have spent so much time there, leaving her situation unattended. Additionally, insubordination is also another concern for Gabrielle such that she was afraid of other nurses picking her workload, rendering her perceived as being useless, consequently risking her image.

Clinical Governance Strategies for Mitigating or Preventing the Incident

Risk management is concerned with the identification, integration, and assessment of systematic risks of potential and current hazards that are related to patient care. The management needs to create an environment where there is a culture of free reporting of errors without risking being reprimanded so that the failures can be identified and potentially averted in the future (Dwyer, 2019).

Risk management involves critical aspects of reporting of clinical incidents. As such, this makes the hospital to improve on the identification of inherent errors and how the hospital can learn from them. A successful system will provide a safe working environment that is non-punitive, simple, inexpensive, and timely. However, there are informational gaps with regards to the implementation of the system that is structured this way, even in the advent of automation of most of the hospital systems (Pasqualetti et al., 2019).

Education and learning are important, given the increased importance of professional and personal development. Continuous and proactive learning in an environment that is reminiscent of the actual working environment is vital going forward. Postgraduate education is always insufficient to ensure that the practitioners are competent and perform according to their mandate since patient-centric medical care also changes with the incorporation of technology in healthcare. Offering education to Gabrielle that goes beyond her ward orientation would have enlightened her further on the protocols to observe, thereby reducing the risk of making errors.

Human resources management and building of teams are critical in the aversion of discrepancies on job domain collision. The incidence was facilitated by Gabrielle's feeling that she would be reprimanded, and this would have taken a toll on her reputation as a budding nurse. The delegation could have besides provided Gabrielle a chance to actively learn, but also execute her functions with the correct delegation parameters put in place. She was afraid of other nurses picking her workload, rendering her perceived as being useless, consequently risking her image. Team building is an essential concept in clinical governance since it is in line with the offering of patient-centred care.

Measuring the Effectiveness of the Strategies

Clinical governance has increased in popularity in contemporary society such that it is often used as a way to measure system-wide health provision processes (Gauld & Horsburgh, 2020). Although risk management is useful in the culmination of better clinical incidents reporting, there are informational gaps with regards to the effective integration of hospital management systems. However, the incorporation of Decision Support Systems (DSS) in the management of risks can be useful in measuring the progress of the clinical governance strategies. Health Technology Assessment (HTA) reports can be used for measuring the effectiveness of the implemented strategies because it offers the opportunity to identify the indirect and direct effects of technology in the provision of quality and safe care (Leggat & Balding, 2017).

Performance monitoring is increasingly being used to measure the effectiveness of clinical governance. However, performance can be better even when the systems are not put in place because of reverse casualty (Buja et al., 2018). Hospitals offering higher quality products typically integrate performance evaluation in their operations (Askari et al., 2017). These kinds of hospital are keen on measuring and demonstrating that they are making significant utility to their patients. The indicators are classified as disease-specific and discipline-specific. Performance monitoring is one of the strategic human resource management approaches that reflect the quality of service. Therefore, strategic resources management can be used for offering employee value addition in terms of continuous development by providing training and education. Thus, the output of these enrolments is monitored and assessed to determine the progress or efficiency of the strategies.


Askari, R., Dolatian, M., Shafil, M., Baghian, N., & Rafiel, S. (2017). Challenges in implementing clinical governance: A qualitative study in Yazd, Iran. East African Medical Journal, 94(1), 44-50.

Buja, A., Toffanin, R., Claus, M., Ricciardi, W., Damiani, G., Baldo, V., & Ebell, M. H. (2018). Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review. BMJ Open, 8(7), e020626.

Donaldson, L. (2018). Clinical governance: a quality concept. In Clinical governance in primary care (pp. 1-16). Boca Raton, FL: CRC Press.

Dwyer, A. (2019). Clinical governance and risk management for medical administrators. In Textbook of Medical Administration and Leadership (pp. 99-125). Singapore: Springer.

Gauld, R., & Horsburgh, S. (2020). Has the clinical governance development agenda stalled? Perceptions of New Zealand medical professionals in 2012 and 2017. Health Policy.

Leggat, S. G., & Balding, C. (2017). A qualitative study on the implementation of quality systems in Australian hospitals. Health Services Management Research, 30(3), 179-186.

Panteghini, M., & Rogers, B. B. (2019). Clinical Governance Should Be a Priority When Care Delivery Systems Are Disrupted/In Reply. Archives of Pathology & Laboratory Medicine, 143(9), 1046-1046.

Pasqualetti, S., Birindelli, S., Aloisio, E., Dolci, A., & Panteghini, M. (2019). Clinical governance remains a priority in total laboratory automation era. The Journal of Applied Laboratory Medicine, 4(1), 130-132.

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