Synopsis
To Err is Human is an in-depth documentary about patient safety in American hospitals. The film documents those working quietly behind the scenes to develop a novel age of patient safety. Through real-world footage of initiatives pertaining safer care, interviews with healthcare leaders, and a family’s journey of empowerment, the documentary provides fresh insight into the future of America’s healthcare system in mitigating preventable harm to patients.
Patient safety is, Mike Eiseneberg, the film’s director, passion. The director is the son of one of the pioneers of patient safety, the late Dr. John M. Eisenberg. Before his death, Eisenberg’s work stirred a national debate on medical mistakes and he was the leader of federal initiatives to enhance patient safety. The director carries on Dr. Eisensberg’s legacy in this film by providing a positive outlook of healthcare quality in the modern system. The documentary also points out ways the system can be improved; hence provides key insights for policymakers.
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The Documentary's Relevance to Today's U.S. Healthcare Delivery System
The documentary illuminates show the healthcare system delivery care system can be improved. For instance, the filmmakers suggest the use Bar code medicine administration (BCMA). The adoption of BCMA system requires essential changes in the workflow for nurses, thus, making them to spend a good portion of their professional time on medication administration as compared to the delivery of other kinds of direct patient care ( Bowers, 2016 ). For example, the leadership of the U.S. Veterans Health Administration medical institutions embraced the use of bar code medication software since they recognized the need for having more emphasis on standardization, usability and even business procedures issues that BCMA end-users have identified ( Truit al, 2016 ). Largely, BCMA has enabled the Veterans Health Administration staffs to make positive changes regarding delivery of patient care.
A good example to explain this is the BCMA Collaborative Breakthrough Project that comprises of pharmacists, nurses, computer support staff and the management personnel. This team set a single goal – to administer and document every medication in 24 hours after coronary artery bypass graft surgery. This goal was established upon realization that delays in medicating patients are likely to produce life-threating outcomes. Notably, implementation of bar code medication administration requires that modifications for workflow for nursing to get the best out of this medication technology ( Truit et al, 2016 ). This way, the nurses as well as the clinical officers use the bar code medication administration system purposely for fostering enhanced safety practices. However, it is undoubtable that by redesigning the medication administration process, proper collaboration and communication between the nurses and pharmacists is a must. This results in enhanced accountability in the process of medication administration.
Leadership Style and Theory
The medical professionals use the situational leadership approach. The leaders typically adjust situations to enable effectiveness and enhance patient outcomes. The paradigm that the documentary illustrates is the six sigma theory. In this model, the health organization focuses on change driven by data to enable better patient outcomes, improve patient experience, reduce waste, and lower health care costs. The objective is to reduce as many issues as possible in regards to patient experience and facilitate high-quality care in the process. Based on the Six Sigma model, the healthcare system has been able to adopt the use of Bar Code medication Administration (BCMA).
Leadership Style and Emotional Intelligence
The documentary illuminates how the healthcare leaders combine situational leadership and emotional intelligence to motivate staff into adopting BCMA . The healthcare workers have learnt to embrace the use of bar code medication to prevent future medication errors. In this case, one prominent problem is the lack of understanding of how the system works. Previously, the hospital and the primary nurse lacked an understanding of safety advantages of point-of-care bar code verification and lack the time to move cart to the bedside of patients. The leaders used emotional intelligence to show that the innovation would give the nurse the capability of scanning the copied wristband in the medication chamber before proceeding to scan medications and deliver them to the patient.
The leaders demonstrated that when healthcare workers want to minimize the medication administration of errors, they should widely use the bar code medication administration systems at every point of care. They also illustrated that the complexity nature of this technology, the BCMA system would simply require supervision by a person bearing the knowledge from all parties involved in it. Such an approach will help to mitigate the negative experiences of healthcare workers like the failure to verify the right patient, medication, time, and dose. The leaders were keen on highlighting that this kind of medication error can be prevented otherwise if not well managed; it can result in improper medication use or patient harm. BCMA system can assist in minimizing such medication errors in the future.
The element of emotional intelligence that the healthcare leaders appear to be lacking is voice. Voice simply means that there is an attempt by an individual to change from the dissatisfying situations, by reverting from an earlier intention to move away or escape such situations. In this situation, employees want to complain about the slacking group members but the organization does not have valid structures to state such complaints. Management should know that employees are full of constructive solutions that can improve the current state of a situation rather than ignoring them (Aravopoulou, Mitsakis, & Malone, 2017). Instead of voicing out in a constructive manner, many employees resort to engaging in a confrontational and counterproductive behavior for the sole reason of winning the attention from the organization so that their requests can be granted.
Ethical and Moral Implications of Documentary
Personal-Take-Away
To Err is Human is an illuminating documentary since it focuses on a serious yet largely ignored issue in the healthcare system. Medical errors are one of the leading causes of death’s in American hospitals. Therefore, the documentary forces healthcare leaders to focus on the issue. The filmmakers are keen to point out ways through the country’s healthcare system can be improved to reduce medical errors and increase patient safety and outcomes.
The most significant strength of the documentary is its practicality. Rather than having a dim view of the health care system, the documentary suggests how the current system can be improved. The second strength is the use of insights from seasoned healthcare professionals. The insights give a real picture of the current status of healthcare system. On the downside, the film fails to show how the suggested improvements can potentially work. It would have been useful to see how the suggestions are applicable in the healthcare system to determine the potential improvements.
References
Bowers, A.M ., Goda, K ., Bene, V ., Sibila, K , Piccin R , Golla S , Dani & F Zell K . (2015). Impact of Bar-code Medication Administration on Medication Administration Best Practices. Computer Information Nursing, 33 (11):502-508
Ross, M. (2019). “6 Medication Error Stories That Made Headlines.” Retrieved from www.blog.cureatr.com/6-medication-error-stories-that-made-headlines
Truitt , E., Thompson , R., Blazey-Martin , D., NiSai, D., Sale,m, D. (2016). Effect of the Implementation of Barcode Technology and an Electronic Medication Administration Record on Adverse Drug Events. Hospitality Pharm acy 51 (6): 474–483.
