Report of the death of Vicky Margaret who died at Albany hospital - Case Study Example

? Report of the death of Vicky Margaret who died at Albany hospital and Contents Contents 2 0 Introduction 3 1.1 Objectives of the report 3 2.0 Background of the report 4 2.1 Analysis of the Case using the Human Factors Models 4 2.2 Analysis of the Case using the Swiss cheese model 4 3.1 Leadership styles 5 4.0 Discussion 6 4.1 Active faults 6 4.2 Latent conditions 7 4.2.1 Lack of specific hospital guidelines and inefficient procedures 7 4.2.2 Unskilled workers 7 4.2.3 Lack of an efficient communication system 7 5.0 Recommendations 7 5.1 Reconstruction of hospital guidelines 7 5.2 Training 8 5.3 Installation of efficient communication channels 8 5.4 Filing records 8 6.0 Conclusion 8 7.0 References 10 Report of the death of Vicky Margaret who died at Albany hospital 1.0 Introduction This report is prepared to help Albany hospital to find out the cause of the death of Mrs. Greeuw, and to help them to prevent such cases in the future. Mrs. Greeuw was forty-five years old at the time of her death, and she had been admitted to the hospital involuntarily eleven days before she died. Vicky Margaret was involuntarily admitted at Albany Hospital because the doctors found out that she had a mental illness, which could not allow her to make an informed decision about whether to get treatment (Hope, 2009). The doctors discovered that Margaret had a mental illness according to the statement given by her mother. The statement argued that the patient was diagnosed with the mental disorder after giving birth to her two children. The hospital diagnosed Mrs. Greeuw with bipolar and schizoaffective disorders. The results of the post mortem conducted by the Chief Forensic Pathologist, Dr Cookie, however, indicated that Vicky died from bowel obstructions. The report that comprised of photographs showed that the bowel obstructions resulted from constipation, which led to vomiting and piling up of faeces in the rectum of the deceased. Further investigation indicated that the medication used to treat the patient was capable of leading to constipation. The medication includes Olozapine, Lamotrigine, Ferrograd, Benztropine, and chlorpromazine (Hope, 2009). All the prescriptions had side effects of leading to constipation, and the doctors failed to examine Vicky’s physical condition. This led to the severity of the case, which consequently led to the death of Vicky Margaret. 1.1 Objectives of the report The main aim of preparing this report is to find out and analyze the causes of the death of Vicky Margaret. The report also aims at formulating recommendations that will help health institutions to prevent similar cases. Health institutions may integrate the recommendations in their policies to ensure that nurses and doctors attend to patients efficiently. 2.0 Background of the report The report was compiled using nursing and laboratory notes and reports, in addition to discussions with critical health officers such as psychiatrists, nurses, and general practitioners. 2.1 Analysis of the Case using the Human Factors Models The Human Factors Model explains that efficiency at the workplace is achieved when human characteristics are integrated into the system of a clinic. The human factors include effective communication, safe working tools, and healthy working conditions. The theory argues that errors are reduced in the workplace when there is efficient communication, and workers use safe tools. In this case, the patient was not examined physically, and there was no proper communication between the doctors who treated Vicky. Griffies, the doctor who admitted Margaret, argued that he was not responsible for the treatment of the patient. Griffies failed to communicate with the doctor who treated Vicky, yet he had some information on her condition. The practitioners also ignored the treatment history of the patient, which shows that Vicky was treated with bowel obstructions in 2005, and she had been admitted to the hospital twelve times since 1989. The case would have been resolved if there was effective communication between the health practitioners who diagnosed the deceased. Attention to Vicky’s medical history would have also helped in reducing the consequences of the situation (Pender, Murdaugh, & Parsons, 2006). 2.2 Analysis of the Case using the Swiss cheese model This model argues that all systems have errors known as holes, and it is these faults that lead to inefficiency. The holes, also known as latent conditions arise from the inefficiency of the system rather than mistakes of human beings (Grober, & Bohnen, 2005). Holes may be active or latent. Active holes are those that relate to poor handling of patients by health practitioners while latent faults relate to poor decision-making at high levels in an institution. Health institutions, therefore, should install defense mechanisms to prevent the consequences of latent conditions. In the case of Margaret, there were both latent and active holes. Active faults resulted from the failure of the doctors to conduct a physical examination of the client; the hole also arose from the ignorance of referring to the medical history of Vicky. Latent faults arose from the inefficient and outdated hospital policies and poor decision-making at the management level (Thornicroft, 2011). The management of the hospital should have installed an efficient system that responds rapidly to emergency cases. 3.1 Leadership styles An integrated leadership style would be helpful in this situation. This is a form of leadership that emphasizes on the production of high-quality output, and it welcomes the views of employees (Landry, 2013). The hospital in this case should integrate democratic and quality control forms of leadership. Democratic leadership is one that encourages firms to involve employees in the decision-making process. Employees may be involved in the process directly, through representatives or quality circles. The management in the organization makes the ultimate decision after considering the views of the workers. This form of management motivates employees to work hard and produce high-quality output. Quality control is a form of leadership that monitors, evaluates, and regulates the procedures and services offered to clients. This style is essential in clinics because services rendered to patients are vital, and they may lead to severe consequences such as death if not monitored. Quality control leadership in a clinic is based on ethics and guidelines that help nurses and doctors to determine the right medication to give a patient (Reason, 2000). In the case involving Vicky Margaret and Albany hospital, integrated leadership would have helped in several ways. First, it would ensure that nurses and doctors follow the hospital policies strictly when diagnosing the patient. The management would have ensured that the hospital workers are involved in decision-making; this ensures that employees give customers quality services while they are comfortable. 4.0 Discussion Human beings make mistakes while executing their duties, and at the same time the inaccuracies may result from inefficient systems. An analysis of the different causes of errors is essential so that it can help in formulating recommendations. 4.1 Active faults There were several active faults in the case involving Margaret; the first mistake occurred when doctor Griffies failed to examine the physical condition of Vicky. The General Practitioner failed to execute this action on the basis of the misunderstandings at the shared care. The lack of physical examination led to the severity of the bowel obstructions that Vick underwent while in the hospital (Parrott, & Crook, 2011). Margaret constipated severally while at the hospital before her death, and she could not explain this situation to the doctors because of her mental deterioration. The patient had also been admitted twelve times at the hospital since 1989, and during these admissions, she was not diagnosed correctly. The patient was also diagnosed by several doctors during these admissions, and each gave a different medication; there was no communication between the practitioners. 4.2 Latent conditions 4.2.1 Lack of specific hospital guidelines and inefficient procedures There were no guidelines specifying the roles of doctors who treat patients in the hospital. The lack of clear policies led to the negligence of the General Practitioner. The doctor was also unaware of the updated hospital policies because he did not receive the new policy manual. This is a clear indication that the hospital procedures were inefficient. 4.2.2 Unskilled workers The nurses in the hospital lacked essential skills because they could not recognize the symptoms of bowel obstructions in the patient. The doctors and nurses failed to diagnose the patient with bowel obstructions due to the lack of recognition of the symptoms. This led to the worsening of the illness that later transformed into death. 4.2.3 Lack of an efficient communication system There were two forms of communication breakdown in the case; first, the practitioners who diagnosed Margaret failed to cooperate. The patient also failed to communicate with the nurses and practitioners because she was mentally ill. The lack of communication between the parties led to the severity of the illness, which would otherwise have been resolved (Garber, Gross, & Slonim, 2010). 5.0 Recommendations 5.1 Reconstruction of hospital guidelines The hospital should reconstruct its policies to make them clear and impose penalties on those who fail to follow the guidelines while executing their duties. This includes highlighting the responsibilities of all workers at the hospital (Grantmakers in Health, 2003). The policies should specify the treatment process of mentally ill people who cannot explain their problems to practitioners. This guarantees the non-discrimination of involuntary patients in the hospital. The reconstruction also involves indicating the procedure of informing workers about new guidelines. This ensures that all workers carry out their duties while following updated hospital guidelines (Mason, Leavitt, & Chaffee, 2012). 5.2 Training The hospital should employ skilled workers who can deliver quality output. The workers should be trained occasionally to ensure that they are capable of serving all types of patients (Reilly, & Markenson, 2011). The employees should also be trained to follow ethical guidelines so that patients receive equal, safe, and desirable treatment. 5.3 Installation of efficient communication channels The management of the organization should formulate an efficient communication system. The system ensures that practitioners treating a patient do so accordingly, and it reduces negligence (Yang, 2008). Employees should be involved in the decision-making process because this motivates them to deliver high quality services. 5.4 Filing records Albany should file records of clients because this helps practitioners in determining the right medication for patients (reason, 2011). This helps the government in conducting an audit of the hospital to ensure that the health care provides quality services. 6.0 Conclusion Mrs. Greeuw died from bowel obstructions, and her death resulted from active and latent holes that were present in Albany Hospital in 2007. The cause of the death has been analyzed using human factors and Swiss cheese models. The analysis indicates that the active holes that led to the death of Margaret include poor communication; while latent faults include unclear hospital guidelines. The leaders of the hospital should adopt an integrated leadership style to ensure that workers carry out their duties effectively. The management of the hospital should also employ skilled workers and train them on occasions to ensure that they deliver services accordingly. The hospital should reconstruct its policies to ensure that the responsibilities of every employee are clearly stated. 7.0 References Garber, J. S., Gross, M., & Slonim, A. D. (2010). Avoiding common nursing errors. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Grantmakers in Health. (2003). In the right words: Addressing language and culture in providing health care. Washington: Grantmakers in Health. Grober, E. D., & Bohnen, J. M. A. (2005). Defining medical error. Canadian Journal of Surgery, 48(1), 39-44. Hope, A.N.S. (2009). Record of investigation into death (Ref No 12/09). Retrieved from http://www.safetyandquality.health.wa.gov.au/docs/mortality_review/inquest_fi nding/Greeuw_finding.pdf Landry, A.C. (2013). Clinical nurse leadership and performance on surgical improvement. Journal of nursing. Retrieved from http://rnjournal.com/journal-of-nursing/clinical-nurse-leadership-and-performance-improvement-on-surgical-unit Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2012). Policy & politics in nursing and health care. St. Louis, Mo: Elsevier/Saunders. Parrott, T., & Crook, G. (2011). Effective communication skills for doctors: A practical guide to clear communication within a hospital environment. London: BPP Learning Media. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice. Upper Saddle River, NJ: Prentice Hall. Reason, J. (2000). Human error: models and management. Us national Library of Medicine National Institutes of Health. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/ Reason, J. (2011). Managing the risks of organizational accidents. Burlington: Ashgate. Reilly, M. J., & Markenson, D. S. (2011). Health care emergency management: Principles and practice. Sudbury, Mass: Jones and Bartlett Learning. Thornicroft, G. (2011). Oxford textbook of community mental health. Oxford: Oxford University Press. Yang, J.(2008). A methodology to model causal relationships on offshore safety assessment focusing on human and organizational factors. Journal of Safety Research, 39 (1): 87-100. Read More