Patient Safety: Life-Threatening Medical Errors - Essay Example

? Patient Safety According to the IOM (Institute of Medicine) report of April 2001, over 100,000 patients dieeach year in our hospitals due to medical errors. This means that patients are dying, not due to their admitting diagnosis or natural causes, but due to a medical mistake. Even more startling is the fact that most of these errors are preventable. The hiking number of patients and their complex medical wants and needs contribute to already vibrant and demanding surroundings. This exerts a heavy toll on budget causing budget deficits, which leads to staff layoffs hence risking many lives of patients in our hospitals (Morath & Turnbull 15). The number of patients seeking medical help is increasing in an alarming rate with more complex medical needs. Despite the increase, medical practitioners should provide the required services. However, with the increase budget deficit, the result is limited staff. Therefore, the staff seeks short cuts to keep up with patient and hospital’s demands. Such dubious short cuts and unreliable options end up recording errors. However, short cuts give emotional side of human behavior (elephant) immediate satisfaction since employees feel efficient and impressive as far as they do not “get caught”, and believe there is no big deal. In order to address this, the hospital introduced organization “Just Culture” whereby “Just” culture organization practices a balanced and equal mode of approach while responding to errors. An approach that transforms staff from being punitive and directs them towards a more “balanced” and “fair” approach. The approach concentrates on faulty systems and procedures rather than personal failure and weaknesses. Research has shown that 80 percent of poor performance results are due to hospital systems failure. In case of a mistake, Just Culture requires the manager to first, listen to the employee who committed the mistake and find out why the employee fell victim of such a risky behavior that caused the error. Through listening, the manager can investigate the system and determine the cause of the error. In our hospital, we have processes set in place to ensure patients safety. Nevertheless, employees will at times look for short cuts to bypass these processes in order to get work done more quickly or satisfy their supervisors. As the switch authors indicate, the elephant stubbornly refuses to comply with safety protocols since it has mastered the art of opting for short cuts and the results for risky behaviors are inevitable. An example of risky behavior is; not conducting a “time out” during surgery to ensure that the right patient is on the table. In addition to desire to get, the job done quickly staff will take short cuts because they fear admonishment or severe punishment from superior staff in the organization. One case in particular gained national attention when a nurse in the operating room refused to speak up while witnessing a surgeon amputate the wrong leg because the nurse feared the wrath from the angry surgeon. All managers attended Just Culture training hence they know what is right and what to do to keep the patients safe, they still engage in risky behaviors because they do not believe that they are putting patients’ lives at risk. All managers received Just Culture Algorithm during training whose aim was to give them guidelines or act as a tool to assist them in dealing with employees who make errors. Yet during my interview for the previous paper with middle managers, I found that only less than a handful of them are using it. The managers, in this case the rider, fully believe in Just Culture and feel that we need to adhere to Just Culture if we want to respond to the Institute of Medicine statistics. However, they are reluctant or rather ignorant to change their ways of punishing employees when they commit mistakes. The managers maintains believe that if they do not respond harshly to errors, employees will not change and, worst yet, other employees will think they can get away with it too. During my interviews with middle managers, they are still punitive and do not use the algorithm explaining why only 20 percent of staff feel it is safe to report errors; according to Patient Safety Culture survey that we distribute annually for the past four years. The Rider, albeit correctly, is not convinced that the manager will practice Just Culture. Therefore, they will not come forward to report errors hence the organization will not get to know about these errors. Therefore, medical errors and mistakes will continue at the same rates. It is important that we persuade the emotional part of managers (elephant) that shifting from being punitive will see staff express faith and trust in them. However, managers do not feel so or see themselves as ambassadors of change in the organization. While the rationale side of them (the rider) understands the value of Just Culture, they do not believe their supervisors (upper management) will support them if they do not respond harshly to mistakes committed by employees in their respective departments. In order to convince the emotional side of managers (the elephant) that they can create the change, I am proposing the creation of a Middle Manager Network (MMN). The MMN would be a vital adjunct to a bright spot in the organization known as the Breakthrough. Breakthrough will prove successful because senior management supports its innovative approach to “change”. Similarly, the MMN could be what we need in a “campaign” for bringing about change and strengthen their roles as agents of change if they collaborated with Breakthrough. I would utilize three root metaphors from the CFAR Campaign Approach paper towards harnessing support: Political, Advertising, and Public Health. The political approach has already kicked off since I have already introduced the concept to MMN to the Executive Director who welcomed the idea and suggested that I proceed with it. Having his support is key and monumental as it gives the campaign affluence and impetus from the highest rank in the organization’s management hierarchy. If the Executive Director gives the proposal consent, it will be hard for senior director who would (at least publicly) disagree with the concept. The moment I knew, I had the Executive Director’s support; I then took advantage of this opportunity to meet the Human Resource Director whom with no opposition expressed excitement upon learning about the idea. I would utilize the other metaphor through public health because I am leveraging support from other key areas in the organization before implementation. While embracing the MMN, the HR Director sees the opportunity to meet the mandate for the work force development. This represents a “win win” situation for both of us. Campaigns to adopt the MMN started and its presence is in the air. A clear path is evident with goals of MMN being short and precise: Improve Communication and Develop a culture of safety where staff would fell comfortable and compelled to communicate errors without fear of retribution. A sense of urgency is felt due to limited time to work see if culture scores have improved (next survey is due March 2012). The collaboration and Breakthrough will foster an identity they previously lacked and champion and make them feel the change. Thus, they will implement the change as a matter of identity rather than consequence. The reluctant middle managers intimidated by the algorithm will have a support system (MMN) that they can rely on and through the engagement; the MMN could take the lead on Just Culture. The logo that could best suit Just Culture is “Keeping It Safe” since it is powerful and the words are easy and simple to understand. The three words envision “strategic theme” and the message while simple it is also strong. It represents urgency and it traps elephant’s emotions since they cannot wait. Part of the campaigning will also include “MMN Coming out Day” as an introduction to the hospital staff. To ensure success of MMN, the hospital should provide the staff with a contract that they must sign. It should read; I am committed to a non-punitive response to errors. I will listen to you when you make a mistake. Furthermore, I will thank you for telling me about your mistake as it will allow me learn about it and conduct and analysis, at risk investigation to prevent it from happening again. Practicing Just Culture will endorse a non-punitive, blame free approach that responds well to our errors. In conclusion, I would like show how my solutions will improve dysfunctional systems or processes that result in life threatening medical errors. We need to create a culture of learning that allows us to view errors as opportunities rather than blame. We cannot achieve this unless the Rider is convinced that he will not face reprimand if he reports a mistake, and he elephant must feel that the pain and loss of a patient is not worth taking short cuts. 100,000 patients are dying each year. This is a matter of urgency given the dangers discussed since the time is limited. The clock is ticking. The time is now for “Keeping it Safe”. Work cited Morath, Julianne and Turnbull Joanne. To do no harm: ensuring patient safety in health care organizations. New York: John Wiley & Sons, 2005. Read More