Occupational Health, Safety and Risk Resilience Case Studies
Professional5 Case StudiesUpdated Sep 2026
Occupational health and safety work sits where staff wellbeing, risk control, and patient care meet. The five cases here come from clinical and care settings, which is where many of the hardest resilience questions show up: fatigue that narrows judgment, handovers that drop a detail, and capacity limits that force trade-offs nobody wants to make. Each case gives a situation, a challenge, two analysis passes, and a set of actions with results. The aim is to practice reasoning under pressure, check it against local protocols, and see how team habits either protect people or quietly fail them.
Case Study 1
Rising observations on an evening medical ward
Thornbury Vale Hospital, a 260-bed acute site with a medical assessment unit and a general surgical service.
The situation
Ruben, a 67-year-old retired courier, arrived at the medical assessment unit at Thornbury Vale with three days of worsening abdominal discomfort and a low-grade fever. The triage nurse, Priya, recorded a heart rate of 104 and a temperature of 37.9 and flagged him for review. The admitting registrar, Tomasz, ordered routine bloods and a urine sample, then left the case for the evening list. Over the next six hours, the notes recorded a drift in observations: heart rate climbing to 118, pain shifting to the right lower quadrant, and reduced urine output. Each entry was small. Taken together, they described a pattern that the early warning score had been quietly climbing toward.
The challenge
The team had to decide whether the picture justified a surgical opinion now or continued observation under the ward's escalation rules. Ruben's bloods were pending. The on-call surgical team was covering two operating rooms and a trauma admission. Priya was uncertain whether a rising score alone met the threshold for a senior call, since the local protocol weighted pain and urine output differently than the score did. She also wondered whether reassessment at the next round would be enough.
Analysis
Teams grounded in Occupational Health, Safety and Risk Resilience start by separating what the patient needs in the next hour from what the chart needs for the next review. For Ruben, the need was perfusion and source control, not a perfect diagnosis. The clinical evidence was a trend rather than a single abnormal value: heart rate up 14 beats over six hours, falling urine output, and localizing pain that had moved. Each change was individually explainable. The useful question was whether the combination matched a process that could cause harm before the next scheduled review, which it plausibly did.
The applicable protocol here was the local deterioration pathway, which asks for a senior review when the composite score reaches a set threshold or when a clinician has a concern that the score does not capture. Priya's concern was a legitimate trigger under that wording, yet the pathway was written to be applied at the bedside, and the handover between the evening nurse and the night registrar had not included the trend. Escalation depended on someone stating the concern aloud. Staff fatigue at the end of a long shift lowered the chance that anyone would. Reading the protocol as a set of prompts, not a checklist, is what keeps a trend from being filed as normal.
Actions taken
- Priya and the night registrar agreed a short handover phrase for any patient whose score has risen across two consecutive sets, so the trend travels with the patient rather than the number alone.
- The ward added a bedside prompt asking the nurse to record whether a concern was raised, and to whom, whenever the score or urine output crossed its threshold.
- Tomasz arranged for the admitting team to pre-brief the on-call surgeon when a patient with abdominal pain has two or more deteriorating parameters, rather than waiting for a formal referral.
- Audit the next quarter of abdominal pain admissions for time from first abnormal observation to senior review, reporting the median and the cases above the local target to the ward governance meeting.
Results
Ruben went to the operating room that evening after imaging showed an abscess. He recovered without further complication, though the review concluded that senior input had come roughly four hours later than the trend justified. The handover phrase and bedside prompt were in use within the month. In the quarter that followed, the audit of abdominal pain admissions showed median time from first abnormal reading to senior review falling from about five hours to a little under two. Two cases still exceeded the local target, and both involved a night shift with a single registrar covering the unit.
Questions for discussion
- Where in the deterioration pathway should a nurse's unspoken concern be recorded, and what does an unrecorded concern cost the next shift?
- How would you weigh an early warning score against a clinician's concern when the two point in different directions?
- Which safeguard in this case depends most on staff fatigue staying low, and how would you test that?
Case Study 2
A held anticoagulant dose lost in handover
Ferncliff Lane Medical Center, a 310-bed community hospital with a surgical ward and a step-down unit.
The situation
Dorothea, a 74-year-old recovering from a bowel resection, was on the surgical ward at Ferncliff Lane Medical Center. At the end of the night, the on-call registrar, Marcus, reviewed her morning bloods and held her next dose of enoxaparin because her creatinine had risen. He wrote the hold into the notes and changed the order to pending review. The verbal handover to the day team, delivered by the night nurse, Aaliyah, covered her wound, her pain plan, and her mobility goals. The anticoagulant hold was not mentioned. The electronic record still showed the order as active, and the medication round template displayed the scheduled dose. Nothing in the handover tool forced a read-back of held or changed medicines.
The challenge
The question for the learners was not who was at fault but where the process allowed a changed plan to disappear. The day nurse, Keisha, was about to give the dose at the scheduled time when a pharmacy technician called about an unrelated discharge. The team needed to find out whether a safeguard had worked or whether they had been lucky. Marcus had left the hospital by then, and the handover sheet did not show what had been decided in the night.
Analysis
Dorothea's needs on that morning were two-sided. Her wound and pain required steady management, and her thromboprophylaxis needed to continue, because immobility after major abdominal surgery carries a real risk of clots. The clinical evidence for holding the dose was her creatinine rising from its post-operative baseline, which changes how enoxaparin clears. A held dose therefore needed a time-limited plan: a repeat renal panel, a documented threshold for restarting, and a named clinician responsible for the decision. Without those, a hold becomes an omission, and an omission can look identical to an oversight.
The applicable protocols were the hospital's structured handover standard and its medication reconciliation policy, both written around the idea that changes made in the night must be stated aloud and matched against the chart. The verbal handover covered what the team already expected, which is the usual failure: the things that changed are the things least likely to be rehearsed. The safeguard that did work was the pharmacy reconciliation call, which happened by accident. Learners should notice that the handover tool allowed completion without read-back, so the protocol existed on paper but was not built into the step where it mattered.
Actions taken
- Add a mandatory field to the handover tool for held, changed, or paused medicines, each requiring a verbal read-back by the receiving nurse before the handover is marked complete.
- Require the night registrar to write a restart threshold and a named reviewer for every held anticoagulant, and make the round template display that note beside the scheduled dose.
- Keep pharmacy reconciliation of new holds within the same shift, with a target of the first two hours after the decision, and track how many holds are reconciled in time each month.
- Run a short simulated handover each month on the surgical ward using a seeded held medicine, then measure whether the receiving nurse names it without prompting.
Results
Dorothea's dose was held correctly, her renal function recovered over the next two days, and the restart was documented with a named reviewer. The read-back field went live within the month. In the first quarter after the change, the audit found that 41 of 46 held medicines were named in handover, up from 9 of 38 beforehand. The remaining misses clustered on nights with agency staff, which the ward is now addressing through a one-page summary sheet.
Questions for discussion
- Which element of the handover standard do you think is hardest to keep under pressure, and why?
- If the pharmacy check had not happened by accident, what would have been the next safeguard, and who would own it?
- How would you decide whether a hold on a medicine belongs in the verbal handover or only in the written record?
Case Study 3
Scarce high-flow units during a respiratory surge
Coldwater Basin Health Network, three hospitals and two community clinics sharing a transfer service and respiratory equipment.
The situation
Coldwater Basin Health Network runs three hospitals and two community clinics, with a shared transfer service and a pool of 14 high-flow nasal oxygen units. In the third week of a respiratory surge, the network's medical director, Imani, reported 22 patients across the sites who met criteria for high-flow therapy. Only 9 units were free after cleaning and checks, and the network had 6 respiratory therapists rostered across three sites, two of them still covering a clinic from the previous evening. Two sites had patients waiting in emergency departments for a bed with monitoring capable of supporting the therapy. Transfers were slowed by a single ambulance crew shared with the clinics.
The challenge
The network could not supply everyone at once. The team had to decide which patients received units, which waited on monitored beds with standard oxygen, and whether to delay elective list starts that would tie up therapists. Lucy, the nurse manager for the emergency department at the largest site, warned that moving the units would leave her own department short. Every option moved risk somewhere else, and the team had to say where they were prepared to accept it.
Analysis
Patients needing high-flow therapy differ in how quickly they deteriorate without it. The clinical evidence the team used was the work of breathing, the oxygen requirement against target saturation, and the rate of change over the previous two hours, rather than diagnosis alone. Patients with rising work of breathing and a rising oxygen need were the priority, regardless of which site they were at. Patients who were stable on standard oxygen with a clear plan could wait on a monitored bed, provided the escalation criteria were written down and understood by the bedside staff. Allocation by diagnosis would have sent units to the wrong people.
The network's surge protocol set out a tiered response: first clinical prioritization by a senior nurse or therapist, then transfer requests through the shared service, then temporary deferral of non-urgent scheduled work. The protocol assumed that therapist time was the binding constraint. It did not say how to balance therapist availability across sites when two sites were both above threshold. The team compared three options: a strict priority list across the network, a site-based allocation with a rebalancing point at fixed hours, and a rotating scheduled review. They chose a combination, and learners should be able to explain why each option alone would have failed.
- 1Clinical priority reviewSenior nurse ranks patients by work of breathing and oxygen need.
- 2Network unit allocationUnits assigned across sites by priority score, not by bed size.
- 3Therapist deploymentTherapists rebalanced to the site with the most patients above threshold.
- 4Elective list deferralNon-urgent lists paused only when therapist cover falls below minimum.
- 5Transfer and reviewShared crew moves stable patients; criteria rechecked each shift.
Actions taken
- Adopt a single priority score combining work of breathing, oxygen requirement, and two-hour trend, scored by a senior clinician at each site, with the score reviewed by a second person before units move.
- Set a rebalancing point at fixed hours each day, so therapists move between sites on a predictable schedule rather than in reaction to each call from an emergency department.
- Pause elective list starts only when therapist cover drops below the agreed minimum of two per site, and publish the pause to affected surgeons and patients the evening before, not on the morning.
- Hold a daily review of patients on standard oxygen awaiting monitored beds, with written criteria for escalating back to priority, and record every delay over six hours for later analysis.
Results
Over the remaining days of the surge, the network kept every high-flow patient who met the priority score on a unit within the target window, though three patients waited longer than the target on standard oxygen. Two of them were moved when a unit was cleaned and freed. Elective lists were paused on two days, and surgeons said the evening notice made rescheduling manageable. Afterward, the network found that its earlier informal practice had sent units to the largest site first, a habit the new score corrected. The surge report recorded median time to unit allocation falling from about two hours to under forty minutes.
Questions for discussion
- What would have changed in your allocation if the largest site had asked for units first?
- How do you judge when deferring elective work becomes a care quality problem rather than an inconvenience?
- Which of the three options compared here would you trust least in a second wave, and what evidence would change your view?
Case Study 4
Uneven falls outcomes across two rehabilitation wards
Marrowby Rise Rehabilitation Service, two inpatient wards and a day program for stroke and orthopedic recovery.
The situation
Across the last three quarters at Marrowby Rise, the service's quality lead, Noor, noticed that the rate of falls with injury varied more between wards than case mix seemed to explain. Ward B recorded a falls-with-injury rate roughly twice that of Ward A, while both used the same falls assessment form. Readmission within 30 days showed a similar gap. Noor pulled anonymized records for 412 admissions, coding each by ward, shift pattern, mobility score on admission, and whether a sedating medicine had been prescribed. The first pass showed no obvious single cause.
The challenge
The indicators were consistent enough to be worth acting on but not clear enough to name a cause. Ward B's staff were starting to suspect the new evening sedation protocol. Ward A's staff believed their nurse-to-patient ratio was the difference. The service had to avoid a fix that addressed one story while leaving the process that actually produced the gap untouched, and it had limited time and staff for a formal study.
Analysis
Patients in this service are often recovering from stroke with reduced balance, or from hip and knee surgery with pain and new mobility aids. The falls with injury that mattered most were in patients assessed as independent with a frame but who were walking unaccompanied at night. The clinical evidence in the records pointed to a pattern: falls clustered between late evening and early morning, most often in patients given a sedating medicine within the previous four hours. That is a plausible mechanism, but the records also showed that Ward B gave the medicine more often, so the sedation and the ward were tangled together.
The falls protocol was consistent across the service and asked for a reassessment after any fall, a medicines review within a set time, and a documented plan for night-time mobility. The gap lay in how the protocol was applied. Ward B's evening team followed the sedation pathway as written, which meant the medicines review sometimes happened in the morning, after the high-risk window. Ward A had a higher staffing ratio but a daytime-weighted handover, and its night staff rarely saw the falls assessment before the first night. Improvement needed to focus on timing and handover, not on blaming a single shift or ward.
- Baseline quarterAnonymized indicators pulled for 412 admissions across both wards.
- First month of changeEvening medicines review moved earlier; night handover adds falls check.
- End of second monthAudit of timing shows reviews still late on busy nights.
- Following quarterNight-shift falls assessment added to handover; rates compared by ward.
- Quarter after thatRates reviewed; change kept, with a monthly check on sedation timing.
Actions taken
- Move the medicines review for any patient prescribed a sedating medicine to occur before the evening meal, so the review no longer falls inside the high-risk window after midnight.
- Add a falls assessment to the night-shift handover checklist, read aloud at the start of each shift, so the first night after admission is planned before the patient is left alone.
- Agree a shared indicator set with both wards, using the same denominator for falls with injury and readmissions, and publish the monthly rates in one table rather than separate ward reports.
- Run a monthly sedation timing audit on a random sample of 40 admissions, measuring hours between medicine and first night mobility, and reverse the change if timing worsens for two months running.
Results
By the end of the second quarter after the changes, falls with injury on Ward B fell to a rate closer to Ward A's, and the gap between wards narrowed without any change to staffing. The timing audit showed most reviews now happened before the evening meal, although about one in five busy nights still ran late. Readmissions dropped less sharply, which suggested a separate cause, possibly discharge planning, that the team has not yet tested. The service kept the change, added the sedation timing audit as a standing item, and wrote the shared indicator set into its quality report.
Questions for discussion
- Which of the two ward explanations would you test first, and what data would you need to test it?
- How would you judge whether a change in indicators reflects the process or a shift in case mix?
- What would make you reverse an improvement that appeared to be working?
Case Study 5
A dialysis decision, a confidential request, and capacity
Saltmarsh Community Hospital, a 180-bed hospital with renal, palliative, and social work teams.
The situation
Walt, a 79-year-old retired machinist, has been on hemodialysis three times a week at Saltmarsh Community Hospital. Three days ago, after a chest infection, he became confused and was admitted to the medical ward. In a calm conversation with the renal nurse, Bianca, he said he wanted to stop dialysis and let his kidney failure take its course. He asked that his wife, Ana, not be told the details of the conversation until he had decided how to tell her. Ana, who holds his health care proxy, had already asked for dialysis to continue at every opportunity. Walt's confusion was improving, but it had not fully cleared.
The challenge
The team had to decide whether Walt had capacity for this decision, how to respect his request for confidentiality without leaving Ana outside a decision that would affect her, and whether the proxy's wishes could override his if he regained capacity. A dialysis session was scheduled for the next morning. Bianca was unsure whether she could delay the session without a documented decision.
Analysis
Walt's needs here are both medical and personal. Clinically, stopping dialysis in advanced kidney failure leads to fluid overload, rising potassium, and uremic symptoms over days to weeks, which palliative and renal teams can manage with comfort-focused plans. The clinical evidence for capacity came from a structured assessment: he could understand the information, retain it through the conversation, weigh the outcomes, and communicate a choice. But his confusion had been present within the week, so the assessment needed repeating on a clear day, with a precise record of what he understood.
The applicable framework combined the hospital's consent policy, the capacity guidance used by medical staff, and the renal unit's protocol for withdrawing treatment. Under those, a patient with capacity decides, and a proxy acts only when capacity is lacking. Confidentiality is not absolute. Walt could ask that his wife not be told details, but the team needed to explain the limits of that request, especially where the proxy's role depends on being informed. Learners should separate three things: what Walt wants, what Walt has asked the team to keep private, and what Ana needs to know in order to act. Those three are not the same.
Actions taken
- Repeat the capacity assessment on the next clear morning with Bianca and the consultant, Erik, present, recording the information Walt was given, what he repeated back, and his reasons in his own words.
- Sit down with Walt and ask him to name what he is comfortable sharing with Ana, and what he wants to keep to himself, then write those limits into the notes in his words.
- Tell Walt plainly that dialysis will continue until the capacity question is settled, and explain that Ana's proxy role applies only on a day when he cannot decide for himself.
- Request an ethics consultation within one working day, and record in the chart who was consulted, the options considered, and the reason the team chose its disclosure approach.
Results
Walt's capacity assessment on the clear morning found that he understood the options and gave consistent reasons. He chose to continue dialysis for now and asked for a family meeting within the week, with the team present when they spoke. The ethics consultation confirmed the approach and recommended a written advance care plan. Walt and Ana met with the palliative team later that week. Bianca noted that the conversation took longer than the schedule allowed, but that the pace suited Walt and gave Ana room to ask her own questions.
Questions for discussion
- How would the disclosure plan change if Walt had lost capacity completely and Ana was the only available decision maker?
- Where is the line between honoring a request for confidentiality and leaving a family member unable to act?
- What would you record in the notes so that a colleague on the next shift could follow the reasoning without asking you?
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