Employing Fishbone Diagram To Analyze Causes Of Failure In Delivering Effective Patient Care

Case Study Illustration

The purpose of this assignment is employ Fishbone diagram in order access the possible causes underlying failure in delivering effective patient care. In order to accomplish this, the assignment will initiate with a patient based on the previous experience of the author. The illustration of the case study will be done on the basis of the guidelines stated by the London Protocol which includes : what happened, Who was involved, When did it happened, how severe was the actual or potential harm, likelihood of recurrence, what were the consequences. After illustrating the case study, a detailed analysis of the risk factors associated in relation to the patient will be done via the use of Fishbone diagram. At the end, the assignment will highlight the aspects of improving safety and the quality of the patient care under the framework of the clinical governance which includes consumer participation, clinical effectiveness, effective workforce and risk management.

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The patient story is based on my previous experience as a trainee residential nurse under age care settings. I was assisting my mentor residential nurse in providing care to a 70 years old woman (Mrs. X) who was suffering from musculoskeletal complications (osteoporosis). That was my second day in the training and my mentor was out for lunch. During this time, Mrs. X stated that she needs to go to bathroom. I helped Mrs. X in getting down from head and provided minimal assistance in her steps towards bathroom. At this time Mrs X stated that she is feeling uncomfortable without her walker but I thought that Mrs. X is suffering from lack of confidence and insisted her in walking independently without the use of walker. Once she entered the bathroom, I stood aside and asked her to seat over the commode independently. Mrs. X took steps forwards and then in an attempt to grip some support near the commode, she lost her balance and slipped on the ground. The outcome of the problem was severe as Mrs X suffered from knee injury and mentally she become scared. Later her sons and my mentor nurse informed that Mrs. X suffers from visual problems. The test undertaken by the neurologist later highlighted that Mrs X has problem in hand-eye co-ordination. The likelihood of recurrence is however, low if proper information about the patient’s healthy history is briefed in detailed to the care giver.

According to the Australian Commission on Safety and Quality in Healthcare (2010, pp.07) in order to improve the quality of care, it is important to listen to the voices of patients and their family/carers who are involved in providing direct care to the patients. This is because direct groups of carers are helpful in providing valuable information in the domain of patient’s health from different perspectives based on their experience. According to the case study, the family members and the registered nurse in residential care of the Mrs. X failed to inform that the patient suffered from visual complications. This poor communication between the family members of the patient and the registered nurse with the trainee (myself) resulted in the accidental fall of Mrs. X. In order to dodge similar situations further, it is the duty of a nurse to explain the patient information in detail during the end their shift timings or while taking a break to the substitute nursing professional. This is known as clinical handover, standard 6 of the National Safety and Quality Health Service Standards of Australia (2012). According to Anderson et al. (2015), clinical handover practices are considered to be an essential component in effective transform of the clinical information between the healthcare professionals. This approach helps to maintain the continuity of care while avoiding unwanted outcome.

Risk Factors Associated with the Patient

The case study also highlights the lack clinical effectiveness. Lack of effective clinical screening tools or the proper guidelines in order to assist healthcare professionals created a barrier in detecting in detecting that Mrs. X suffered from poor hand eye co-ordination. According to Shatil (2013) older adults who are aged over 65 years suffer from poor hand eye-coordination. It is the duty of the nursing professional to identify. In case Mrs. X difficulty in hand-eye co-ordination can be judged on the basis of the vision impairment or the lack of proper eye-sight and in relation to age of the patient. Murata et al. (2013) stated the importance of the vision-related quality of life (VRQoL) prediction system in order to highlight the visual field (VF) test points, which is associated with the reduced VRQoL in older adults. The application of this clinical effectiveness might have helped to dodge the unprecedented fall of Mrs. X. Use of proper effective clinical tool and drawing the reference of her lack of proper eye sight might have helped the nursing professional to gauge the chances of difficulty in and eye co-ordination.

To form an effective workforce all the professionals in the healthcare domain are required to have proper skills and knowledge and must work collaboratively (Auerbach et al., 2013). The analysis done via the Fishbone diagram identified the few of the possible causes of incompetency with the existing clinical workforce and this includes poor teamwork, lack of proper knowledge and skills and lack of proper experience. The lack of proper co-ordination between the trainee nurse (me) and the mentor nurse (the registered nurse in the residential care) lead to gap in the transfer of the effective information. Thus it is the duty of the registered nurse to indulge in effective communication with the other healthcare professionals so that none of the important information in the domain of patient care is missed or neglected. According to Kourkouta and Papathanasiou (2014), proper communication between the healthcare professionals is important for the successful outcome of the individualized nursing care approach. This effective communication skills will also help to increase the experience in the over process of care. Kourkouta and Papathanasiou (2014) further highlighted that effective communication requires an understanding of the patient feelings. It requires skills and simultaneously the sincere intention of the nurse to understand the concern of the patient.

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According to Australian Commission on Safety and Quality in Healthcare, clinical leaders and the senior managers of the healthcare must work effectively in order to implement systems for the prevention of patient falls or minimization of the chances of accidental falls to the older adults. Carande-Kulis et al. (2015) highlighted proper manual assistance in walking, use of portal toilet seat, walker and shoes soles with special traction might proved to be helpful in preventing the chances of encountering fall among the older adults. In case of Mrs. X round the clock manual assistance is primitive in effective risk management of accidental fall. Robertson and Gillespie (2013) further recommended that it is the duty of the healthcare professionals to include proper muscle strengthening and balance retaining exercise in order to reduce the chances of accidental falls among the older adults. Proper supplements of the vitamin D diet will also help in effective fall prevention among the older adults who are suffering from osteoporosis.


Thus from the above discussion, it can be concluded that, lack of proper communication skills, proper transfer of the patient information through clinical handover and lack of proper experience and knowledge in patient care resulted in the accidental fall of Mrs. X. The assignment also highlighted that older adults are prone to accidental fall and it is the duty of the healthcare professional to perform proper risk management in order to avoid the chances of impending fall.


Anderson, J., Malone, L., Shanahan, K., & Manning, J. (2015). Nursing bedside clinical handover–an integrated review of issues and tools. Journal of Clinical Nursing, 24(5-6), 662-671.

Auerbach, D. I., Staiger, D. O., Muench, U., & Buerhaus, P. I. (2013). The nursing workforce in an era of health care reform. New England Journal of Medicine, 368(16), 1470-1472.

Australian Commission on Safety and Quality in Healthcare. (2010). Australian Safety and Quality Framework for Healthcare – putting the Framework into action: Getting started. Access date: 13th September 2018. Retrieved from: https://www.safetyandquality.gov.au/

Australian Commission on Safety and Quality in Healthcare. (2012). National Safety and Quality Health Service Standards of Australia. Access date: 13th September 2018. Retrieved from: https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf

Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015). A cost–benefit analysis of three older adult fall prevention interventions. Journal of safety research, 52, 65-70.

Kourkouta, L., & Papathanasiou, I. V. (2014). Communication in nursing practice. Materia socio-medica, 26(1), 65.

Murata, H., Hirasawa, H., Aoyama, Y., Sugisaki, K., Araie, M., Mayama, C., … & Asaoka, R. (2013). Identifying areas of the visual field important for quality of life in patients with glaucoma. PloS one, 8(3), e58695.

Robertson, M. C., & Gillespie, L. D. (2013). Fall prevention in community-dwelling older adults. Jama, 309(13), 1406-1407.

Shatil, E. (2013). Does combined cognitive training and physical activity training enhance cognitive abilities more than either alone? A four-condition randomized controlled trial among healthy older adults. Frontiers in aging neuroscience, 5, 8.