Organizational processes have been identified as one of the major causes of errors and failures in the healthcare sector. Organizational processes that have weaknesses and lack appropriate policies, as well as the right procedures and communication channels, can lead to errors. For example, lack proper communication channels and procedures within the organization can lead to misunderstanding and subsequently result in a failure or an error. The overall processes within the organization including the staffing pattern and workflow can also lead to failures if there is a weakness in any of these processes. In the case study, there must have been lack of proper communication and non-procedural workflow in the organization supplying oxygen to the nursing home, and this could have led to the error.
The physical design of a healthcare facility can create a condition deemed conducive for errors to occur. There is a relationship between human beings, their working environment, and the tools they use on the work performance (Gharaveis, Hamilton & Pati, 2018). People are more likely to cause an error or accident when they work in an environment that is poorly designed. For example, low lighting levels in medication dispensing area of a healthcare facility has been greatly associated with increased medication error.
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Sharp end individuals are those care providers who are in direct contact with the patients. The major errors committed by these individuals include medical errors such as wrong-site surgery which can result to harm on the individual patients. Other errors include the wrong diagnosis of the patients which ultimately leads to wrong medication thus putting the life of the patients at risk.
Every healthcare organization requires to have safety regulations that protect the safety of both the patients and staff. A breach in any of the safety policies could ultimately lead to serious medical and medication errors as well as accidents. There is a need to adhere to the safety regulations and follow the due procedure, ensure workflow and adequate communication to prevent the occurrence of such errors.
The FDA is responsible for investigating the case because the organization is responsible for regulations and protection of the public health by ensuring safety and efficacy of human drugs, food, medical devices, and other products delivered to the healthcare facilities for patients use (Pitts, Le Louet, and Moride, 2016). It ensures that every drug and products that patients use are safe and not risky to their health. Oxygen provided to the patients with respiratory problems fall under the products that FDA regulates, and thus it is the one responsible for investigating the matter in the case study. OSHA, on the other hand, is concerned with the safety of the workers and ensuring safe working conditions, and its mandate does not entail overseeing the safety of drugs and other medical products to the patients.
In the culture of safety model, the safety of the patients is the core aim and entails a collaborative commitment to safety. In this model, everyone in the organization is responsible for safety, and all staff members take safety as a shared priority and the first goal for the organization (Ulrich & Kear, 2015). Once a safety culture is introduced through beliefs, values, and attitude of everyone in the organization, it becomes the leading goal for all staff members. In the case scenario, the safety culture model could have led to everyone being concerned about the safety of the patients as the priority. In this case, the nurse who connected the nitrogen tank to the patients could have verified the exact content of the tank given that the tank had two labels. The nurse could have engaged with other members to enquire the safety of the content of the tank through various safety procedures set by the organization.
The five major principles of the culture of safety model include teamwork, patient safety, and patient-centered care, accountability, patient involvement, and transparency. Teamwork entails creation of a culture of collaboration and consultation amongst the staff members. Working together as a team to solve problems and to identify issues that require attention is key to promoting safety of patients. Teamwork enhances communication thus reduce errors that can occur due to miscommunication (Ulrich & Kear, 2015). Patients’ safety and patient-centered care involve a culture where everyone in the organization puts the safety of the patients as a priority. It aims at making patients safety as the overriding goal for every caregiver. This will ensure that every action taken by the staff is aimed at promoting the safety of the patients. When there is a culture in which every staff is concerned about the safety of the patients and provides patient-centered care, incidences of error and other failures can be reduced due to complete commitment to the safety standards set by the organization.
The principle of accountability aims to make everyone accountable and responsible for every action they take. The goal is to ensure that all staff members are responsible for their actions, and are therefore needed to remain competent in their duty and to put the patients first. Patients’ involvement, on the other hand, requires that care providers engage patients in their treatment through improved communication and collaboration. The working together of both the patients and care providers can help reduce errors due to increased sharing of information and trust. Transparency principle on the other promotes openness between the care providers, the management and the patients in a way that creates trust and leads to sharing of information on the safety of patients.
Under the principle of teamwork, the action that could have been taken by the nursing home to manage the risk involve consultation and collaboration with other staff members. The employee who connected the tank containing nitrogen could have consulted with other staff members upon realizing that the tank had two labels, and this could have provided a solution before the risk occurred. In the patient safety principle, the employee could have verified the content of every tank before connecting it to the patient to ensure that it was the right content that is safe for patients. The principle of accountability holds every nurse responsible for their actions, and as a result, the employee would have first verified that the tank had the right content before giving it to the patients as he/she would be held responsible for any negligence. Transparency principle requires openness and trust between all people in the organization, and with this culture, the employee would have communicated with other staff members and management on the two labels on the tank before giving it to patients. On the principle of patients’ involvement, the employee of the nursing home would have involved the patients through communication and trust before connecting the oxygen tank. All these actions could have prevented the risk by identifying that the tank had the wrong content for the patients.
References
Gharaveis, A., Hamilton, D. K., & Pati, D. (2018). The impact of environmental design on teamwork and communication in healthcare facilities: a systematic literature review. HERD: Health Environments Research & Design Journal , 11 (1), 119-137.
Pitts, P. J., Le Louet, H., Moride, Y., & Conti, R. M. (2016). 21st-century pharmacovigilance: efforts, roles, and responsibilities. The Lancet Oncology , 17 (11), e486-e492.
Ulrich, B., & Kear, T. (2014). Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery. Nephrology Nursing Journal , 41 (5).
