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the reflection of the registered nurse using Gibb’s cycle




The essay depots the reflection of the registered nurse using Gibb’s cycle. The Gibbs model comprises of description,, feeling, evaluation, analysis, and conclusion. The essay describes the view point of the registered nurse during the critical situation. The case study reveals the loss of  patient in hospital setting due to human factor error (Just a routine operation).


One day, my duty was scheduled in the emergency department as the physician support nurse. In the operation room, some issue cause some cardiac problem to patient. The patient showed vital sign and was unable to respond. All the physician and doctors were working hard to save the life of the patient. At the end, the doctor transferred the patient to life support and was practicing all the best possible ways.  Then with all the practice, the patient was transferred to the recovery department. However, due to certain factor, the entire medical provider was unable to save the life and patient died.


I experienced worse feeling in the operation room because this was my first experience where it is becoming difficult for the doctors to save life of patient. I can recall that sense of worst situation now also after 2 years of my services.  The other senior nurse and doctors are working hard and applying all the best possible way to save the life of the patient. The neglected feeling arise in me because in the presence of experience doctors, experience nurse, and experience health care provider, we were unable to save the life. II think that there is some negligence factor, which is responsible for the death of the patient. Furthermore, during that situation, ll the medical practitioner were working with full force and action, however, we could not be able to save the life of the patient.


The situation depict that there are various factors, which are responsible for the misfortunate death of the patient. Before the operation, the patient was healthy and in conscious state. During the operation, there occur some negative things, which has worst impact on the health of patient. Suddenly, the patient shows vital sign including decreased pulse rate, decrease respiratory rate, and decrease heartbeat. Due to some negligence in the clinical practices, the patient died. I think there is some breakdown in decision making that has been done while proceeding with the patient health. Green, (2016) opined that a mistake in healthcare is a significant factor for harmful and fatal situation. I think there are some considerable human factors which are associated with eventual death of the patient the factors contribute miscommunication, inferior security check, degraded implementation approach, and worse situation handling approach.


Timmon (2016) state that aviation-derived human factor training is an important approach that should be practiced in health care professional. I totally agree with the Timmons thought as these things help in ensuring the patient safety and adoption of best clinical practice approach. These practices help in professional working as per National Health Standard and clinical practice standard. The contributing factors that are responsible for the human error includes workload, poor interpersonal communications, leadership issues, inferior cognitive process, flawed decision making, and bad team work (Heard, 2015). I believe that these factors are responsible for the eventual death of the patient in the situation as well. The physician or the doctors usually practice the leadership qualities and often create the situation of negligence. This may further effect the decision making process and thus result in inferior decision implementation.


Action Plan

From the above discussion, I believe that there must be incorporation of human factor in the healthcare organisation similar to the aviation-based. This help in implementing the safe delivery of the health care to the patients. Safe, proper communication, skilled decision-making, and in-compliance with health care standards ensure the proper clinical practices. Jones, et al., opined that efficient task performance activity can be achieved by removing or reducing the communications glitches, hierarchical barriers, teamwork miscommunication, and cognitive biasness. These thing an be removed through proper training of the registered nurse, open discussion and communication with the team, doctors, and physicians, quality check of the implementing procedure before initiating the clinical practices as this will help in identifying the loopholes of the procedure. The physicians should thorough check the patient medial status before implementing the operation (Green et al., 2016).


From the above discussion, it can be concluded that the in the health care organisation, there arises many situation when the patient died because of the degraded work status of health organisation. However there are very minute professional parameters that should be taken care and must be implemented to ensure the safe health of the patient. The contributing factors that are associated in normal day to day activities in the health care organisation are miscommunication, lack of awareness, breakdown of leadership, situation handling, security checks, inferior Knowledge, worst decision making, and accident due to human factor. These factors directly or indirectly associated with the safety, healthy, and wellness of the individuals. I think if the proper communication was done before the implementation of the treatment than we could save the patient. Proper health management guidelines should be prepared an must be distributed to every member of the team than the condition could be better than today.




Eltaybani, S., Mohamed, N., & Abdelwareth, M. (2018). Nature of nursing errors and their contributing factors in nursing care units. Wiley Online Library, 24, 47-54. Doi: https://doi.org/10.1111/nicc.12350

Green, B. , Tsiroyannis, C. & Brennan, P. (2016).Human factor – recognising and minimising errors in our day to day practice. Oral Dis, 22, 19-22. Doi: http://dx.doi.org/10.1136/emermed-2013-203203

Herd, G. (2015). Errors in medicine: A human factor perspective. Australia Anaesthesia, 1-11.[L1] 

Jones, C., Corbett, F., Morton, B., Lister, C., & Mercer, S. (2018). Human factors in preventing complications in anaesthesia: A systematic review. The Association of Anaesthetist of Great Britain and Ireland, 73, 12-24. doi:10.1111/anae.14136

Just a Routine Operation. Retrieved from https://youtu.be/JzlvgtPIof4

Timmon, S., Baxendale, B., Buttery, A., Miles, G., Roes, B., & Browes, S. (2016). Implementing human factors in clinical practices. Emergency Medical Journal, 32, 1-10.



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