1) I expected to learn about building a culture of safety in
the healthcare environment.
2) I actually learned about ensuring risk management teams
are available in health care settings to build cultures of safety. In healthcare,
there are multiple potential possibilities for death and disability. The vision
of risk management is to build resilient systems with a goal of zero avoidable
harm. Risk can be measure in terms of likelihood and consequences. Human error,
performance limitation and accidents are all potential risks. Safeguards and
systems need to be put in place to foresee and plan for risk, implement
processes to decrease risk, and recover from adverse events.
Organizing a culture of safety involves leadership
commitment, trust in communication, shared importance on safety, teamwork and
support/encouragement, and reporting/analysis systems (Pronovost, et al.,
2003). Most methods suggest focusing on the clinical microsystem where physicians
and patients meet, and then focusing on a meaningful change. Methods also
suggest viewing the whole causal system and not just a single root cause.
Risk management aims to ensure healthcare providers are
acting in the best interests of the patient. If errors do occur, patients and
their family members should be informed about it and the cause of it.
Disclosure is very important following errors in hospital settings. This way,
improvements can be made and others can learn from the experience to prevent it
from happening again.
3) The article “It’s Hard to Kill a Healthy 15-Year-Old” (Johnson, Haskell & Barach, 2012) made me sick inside to read. I was honestly amazed at how poor of communication
and care processes this single patient received. The patient was hemorrhaging
internally with peritonitis, tachycardia, poor pulses, paleness and abdominal
pain. There were so many signs pointing out that something was extremely wrong
with the patient. I mean, when a nurse
gives a pain medication, and the pain continues to persist or worsen, other
forms of medication should be considered while discontinuing the one causing
increased discomfort or symptoms. A
nurse or pharmacist could have double checked to ensure the dosing was proper
for the patient, or even determine whether the medication was appropriate for
his age category. I was shocked that they were ambulating the patient to
relieve him of his “gas pains” while he was hemodynamically unstable. It just
makes me sick to think about, and I feel so bad for the mother, father and
sister that had to deal with his tragic death.
This depressing and devastating case study proves to me how
important wearing a badge is that indicates one’s title and abilities. It
proves to me how important communicating with physicians and other experienced
professionals is when patients display initial signs of worsening. I
appreciated that the parents tracked down the patient’s information and
remained diligent in finding his cause of death. What if she hadn’t? No
Hospital Patient Safety Acts would have been created to help protect other
patients. I hope all health care facilities have risk management teams to
ensure safe implementation of processes where risks can be foreseen and
prevented.
4) I plan to disclose the cause of errors with
patients/family members and filling out an Incident Report form so risk management
teams will be aware of problems in the microsystem and can help plan ways to
fix them so other patients can be protected. (My goal, of course, is to not let
errors occur—as is all well-meaning care providers.)
5) I will restate my personal feelings about the case study.
It is entirely devastating that a family lost their son to a chain of errors
from incompetent providers. Yes, hindsight makes things easier. A novice nurse
being told by a resident physician her patient has gas pains, will likely not
doubt and continue to believe this fact (while simultaneously causing more harm
to the patient by ambulating him). A more experienced nurse will question what
the resident says and look deeper into the problem at hand with the patient.
The nurse will also take action to make things better for the patient!
References
Johnson, J., Haskell, H., & Barach, P. (2012). The Lewis
Blackman Hospital Patient Safety Act: It’s
hard to kill a healthy 15-year-old. In C.P. McLaughlin, J. K. Johnson, & W.
A. Sollecito (Eds.), Implementing continuous quality improvement
in health care: A global casebook
(pp. 5-14). USA: Jones and Bartlett Learning, LLC
Provonost, P., Weast, B., Holzmueller, C. G., et al.,
(2003). Evaluation of the culture of safety: Survey
of clinicians and managers in an academic medical center. Quality Safety in Health Care,
12: 405-410.
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