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Clinical governance approaches in most hospitals has been trenchantly criticized in reviews. It is therefore necessary to effect reform to clinical governance, but this should not be seen as only being about traditional ‘safety and quality’ policies. Clinical governance should essentially be about professional and organizational accountability for quality. It is important in hospitals and in health services in that it guarantees that the patients are given the best care and the doctors, nurses and other medical workers are properly taken care of. Good clinical governance requires the safeguarding of high standards of care by creation of an environment on which excellence in clinical care can flourish. Under the government's market driven health system, many feel that the quality of professional care has become subservient to price and quantity in a competitive ethos. This has lead to serious clinical failures like the one described by Mrs. Smith’s case and other cases such as in breast and cervical cancer screening programs. Other advantages of good clinical governance are efficiency in resource use, risk management and patient’s satisfaction with the service offered. Clinical Risk Management is being used because reduction of medical error and the improvement of the patient’s safety is increasingly a priority for all hospitals. This is where clinical risk management comes in. It basically provides a strategic approach to improving patient safety – it does this by identifying the frequency and nature of medical errors and consequently developing ways to reduce the likelihood of such errors occurring again in the future. The theory of clinical risk management simply acknowledges that all healthcare activity carries a risk which is as a result of many reason, some accidental, some as mistakes. Systematic clinical risk management involves identification of the risk, analysis of the risk, treatment of the risk and evaluation of these risk treatment strategies. It is beneficial in that it reduces the risk of being sued in the case of injuries inside the hospital like with Mrs. Smith. This information and related information can easily be obtained from the government policy papers and from the many online and offline publications on the same.

Key quality and safety issue in Mrs. Smith’s case

Given that Mrs. Smith has Osteoarthritis, her mobility is restricted, has poor vision due to retinopathy and peripheral neuropathy and she has a bad right hip that is awaiting replacement, if the FRAT tool had been used, it would have been seen that her risk of falling was high and there should have been a nurse watching over her all night through. The fact that she had indicated that she has a weak bladder called for a nurse to look out for her through out. Again, given the results of the FRAT tool, the hospital should have noted Mrs. Smith’s risk of falling as it admitted her and they would have acted accordingly. Lack of doing this show a lack of quality in the medical services offered and disregard to safety issues. Disregard of quality issues also rises from the fact that there was only one nurse looking after all the patients in the ward during the night shift. It is a fact that most people are actually sickest during the night and there should have been more personnel working. If FRAT analysis would have been done, there would have been a commode at bedside and there would have been a toileting program for those that are a high risk of falling like Mrs. Smith. On attending to Mrs. Smith after her fall, she said that she tried to call out for help and this means that the bell was out of reach. This poses a serious safety issue because something more serious than falling could also have happened given the results of FRAT. Mrs. Smith claimed that the toilet was not where it was supposed to be. This shows that the lighting was not good enough given her eye problem resulting from retinopathy and peripheral neuropathy and the hospital compromised her safety by not taking this into consideration. From the lack of FRAT, we can conclude that staff education in the hospital was lacking and this lowered the quality of care and compromised safety in the case of Mrs. Smith. The nurse responsible for Mrs. Smith and others in the ward had gone for a break when the accident happened. This posed a serious safety problem because she did an inadequate handover to a person who was not really responsible even if there was a problem – the nurse was responsible for everything.

Analysis of events leading up to the incident

Using the 5 Whys method of root cause analysis, the problem is that Mrs. Smith fell.

What happened was that Mrs. Smith fell when she should not have fallen. The had told the nurse clearly that she had a weak bladder and that she would need to go to the toilet at night, but the nurse went ahead and put her frame and the bell away from her reach. Even after stating that her eyes were weak and stating her problems in moving around, the nurse went ahead and left the room for a break. The hospital should have put more nurses on call at night to prevent such cases. The hospitals should have done a FRAT analysis the moment Mrs. Smith arrived at the hospital and this would have prevented the accident also. The nurse should have made sure that everything was accessible to Mrs. Smith because she had been informed by Mrs. Smith that she would visit the toilet at night because of her weak bladder. It is likely that the nurse failed to take care of Mrs. Smith as she was supposed to due to lack of education on FRAT and related topics – the hospital should have made this education a priority. The consequences were a terrible accident that relocated Mrs. Smith’s hip. This reduced the hospital’s credibility and put its safety policy into question. Another consequence was risk of legal action by Mrs. Smith. Field and Lohr (1992) state that, ‘Risk management programs attempts to evaluate and decrease liability risks related to clinical care, housekeeping functions, management decisions, and other sources. Liability claims may arise from adverse events experienced by patients, visitors, staff, and others – even by prospective patients turned away from care.’ If Mrs. Smith would have wanted to sue, she probably would have won. Errors will always occur if there are no appropriate defenses and safeguards as seen in Mrs. Smith’s case where she didn’t have a nurse paying close attention to her. The nurses were responsible for any eventuality in the hospital during the night shift and any error that would occur would be blamed on them. The hospital should have put systems in place to prevent this situation because nurses are only human and errors will always occur. If they had put measures in place, these errors would have been prevented.    

Strategies for improvement

The hospital should train the staff on FRAT and on other safety issues and it should try to create a safety culture by advancing the ‘Think Safety’ mentality. Haynes & Thomas (2005) stated that, ‘Clearly medical staff will always continue to learn more about clinical medicine throughout their working lives, and to refine and develop their clinical skills, but they increasingly need to address areas which are not primarily clinical at all, such as leadership, management (including risk management, audit, information technology and educational skills). These are professional rather than purely medical matters.’ The hospital should rethink their individual versus system policy and so it should not blame individual nurses and doctors for such cases as Mrs. Smith’s accident. Haynes & Thomas (2005) stated that, ‘...is primarily an educational process that is based on dialogue and interaction with the appraiser, and which focuses on the development needs of the individual. It should be a structured process to facilitate self-reflection, and should allow the individual to review their professional activities comprehensively and to identify areas of real strength and areas of need of development.’ The hospital should do risk assessment as part of their policy and it should have implementing solutions. This can be achieved by doing FRAT analysis and other risk assessments before or as a patient is being admitted into the hospital. The hospital should make sure that there are more nurses during the night shift and finally, the hospital should take matters of clinical governance more seriously. On this issue, Haynes & Thomas (2005) stated that, ‘Clinical governance is a framework for the improvement of patient care through commitment to high standards, reflective practice, high management, and personal and team development.’ If good clinical governance and clinical risk management had been in place, Mrs. Smith would have had a nurse nearby, every thing would have been where it should and she would not have fallen. The hospital should get regular external audits of its facilities, its staff and of the services it offers. An independent review would have brought the need for FRAT to the doors of management, it would have recommended more nurses per patient during the night shift, it would have demanded more accessible facilities for patients with a high risk of falling such as Mrs. Smith and it would have recommended the training of nurses and other members of the staff on falling risk management. This would guarantee patient such as Mrs. Smith are taken better care of.

As seen from Mrs. Smith’s case study, good clinical governance and clinical risk management are essential for the running of a hospital and a health system. The benefits of this are to the hospital, the hospital staff, the patient and the society. When a sick patient walks into a hospital, the staff should do a FRAT immediately, especially if she is aged. The hospital should also make some policy changes such as increasing the number of nurses during the night shift, changing the system instead of blaming individuals and training the staff to ‘think safety’ at all time. Lack of an effective risk management program would lead to patients taking legal actions, the hospital losing money, the staff being overworked and many other problems.