Inadequate Communication and Medication Errors
Discuss about the Organizational Skills and Psychology.
This paper assesses the issues relating to poor safety culture at Sacred Heart Hospital and provides recommendation to the management for their consideration. Safety culture can be said to be the way patient safety is conceived among member of the staff of a hospital or a health care facility while discharging their respective mandates in the treatment process of the patient. It is human nature to find shorter ways of accomplishing tasks within the shortest time possible even though this has some ramification on the quality of the output. The Hospital is faced with poor safety culture and this has been entrenched further by the fact that accidents at the hospitals is at all time low. While this is a fact this paper has raised compelling issues that are likely to tilt statistics against hospital regarding accidents arising due to poor safety culture in the Hospital.
The survey carried out at the Sacred Heart Hospital raised a number of ‘normalized’ behaviors that exposes patients and medical staff at the hospital at risk. The Hospital staffs have a tendency of not checking patient identification using two names, not checking patient allergies and medication profile while prescribing drugs. There is also communication problem among the staff especially when changing shift in that the outgoing staffs are always in hurry to leave as long as his/her colleague to replace him have arrived. There is also use of dangerous abbreviations that can be easily miss- understood (Raeisi, Nazari, &Bahmanziari, 2013).
The consequences associated with above poor safety culture are enormous. According to the survey done by the writer of this paper the Hospital receives an average of eight hundred patients per day. This is a significant number of people and by not checking the identification of patient using two or more names increases the risk of packing wrong medication to the patients. This will simple but crucial procedure can be fatal at times because the patient will continue taking wrong medication and may fail to return to the Hospital to complain of not getting well even after taking the medication. This is quite common phenomenon among the patient has 29% of the 100 patients interviewed randomly indicated that they are likely to take considerable time of about two days after taking medication to see if the drugs prescribed will help them recover. If you consider this time and having wrong medication then you will realize that it is likely that the resultant effects of taking wrong medication may not be easily reversed. Some drugs are have instant effects and won’t even give time for diagnosis incase the medical history of the patient isn’t available at the time the patient is seeking medical assistance. There is need for the Doctors to Identify patient using two or more names to avoid confusing patients dosing. Sacred Heart Hospital will save itself a great deal of Public outrage or disciplinary actions by the regulatory agencies if this simple mistake leads to a patient losing his or her life as a result (Jeong, 2015).
Hierarchy Disrespect Issues
Inadequate communication between staffs when changing shifts is likely to lead to improper handover of the patients. This can lead to overdosing or under-dosing of the patient in future as a result of inadequate information or lack of it if the culture is left to continue and unchecked. 52% of the 22 Physicians both locum Doctors and permanent Doctors indicated that they usually leave the written records of the patients records for the incoming Doctor to acquaint him/herself without necessarily providing oral briefing. The oral briefing during handover is good because the Incoming Doctor can also ask questions where he doesn’t understand and seek clarification as opposed to leaving only written information and it is upon his or her wisdom to make judgment which might not be the best because he she hasn’t been observing the patient for some considerable time to make solid judgment. This is likely to lead to delays in administering medication as the fresh Doctor may want to take some time to observe the patient before making a decision on what needs to be done. This will in turn lead to congestion of the facility and the management might be duped into incurring investments in expanding the facility in response to ‘apparent’ congestion in the Hospital while the same could have been avoided by simply changing the safety culture of insuring Doctors during hand over do proper written and oral orientation to the incoming colleague (Wolff & Taylor, 2009).
The Hospital is also facing hierarchy and disrespect issues among some members of its staff. Doctors have a tendency of dismissing their colleagues’ observation simply because they are the Physicians. The problem arises from a culture of Doctors looking down upon the nurses and other medical officers that has been in practice for a long duration in the hospital especially when the consultant Doctor is at home and the nurse is calling to make an observation and seek advice. One of the Nurse interviewed reported on an incident in which she called a consultant Doctor at home to inform him of the abnormal vital signs in a body of an expectant mother. The Doctor dismissed her observation saying the condition she is raising shouldn’t be happening the same condition is associated certain type of pregnancy which according to him wasn’t the case with the patient in question. Despite not being present at the Hospital to make fast hand observation the Doctor stuck to his remote observation and the Nurse had to content with that despite having made a valid observation at that time which the same consultant Doctor made when he came in after his break. The condition was likely to lead to serious complication to the patient and in future it may not have a luxury of time to wait until the consultant is in to make the observation him/herself. This presents a significant risk and may result to problems in future including losing the patient. It is necessary that this culture is corrected at the Secret Heart Hospital to encouraged team work among members of the staff so that the Hospital can accomplish more in shorter period of time and in a safe way (Jeong, 2015).
A significant number of the Sacred Hearth Hospital staff interviewed admitted of not continually washing their hands and changing gloves when it is necessary. Of the 83 staffs interviewed in the course of the study 42% of them admitted to practicing this culture because they have seen their colleagues doing it and no serious accident as occurred as a result. During the Delivery of the babies Doctors and nurses rarely change gloves thus exposing the mother and the child to health risks. Most of the deliveries at the Sacred Hearth Hospital have been successful thus further entrenching this ‘normalized’ culture. In an event that medical practitioner at Hospital fails to wash his or her hands or change gloves before attending to another expectant mother the patient at the new station may be exposed to germs or/and diseases causing micro organism. This may eventually harm the new born baby as well. Thus this needs to be addressed by the management of the hospital to avoid such cases arising in future.
On the issue regarding communication, all the staff should be sensitized on the importance of taking time to do proper handing in/handing over to avoid risk of future problems that may arise as a result of inadequate preparation. The fact that the Sacred Heart Hospital hasn’t recorded any accident as a result of this poor safety culture doesn’t mean it won’t happen in future. The Hospital should conduct in service training to its staff on the need for the proper hand in/out.
The trainings can be conducted in phases so that it doesn’t lead to shortage of staff while the training is ongoing. All the employees should eventually be involved in these trainings because this aspect is important even to the record keepers at the Hospital and other non-medical staff. During the training, members of staff should be placed in similar profession because the details of what is contained in the training program vary from one type of profession to another. For Doctors all the specific items that need to be handed over to the next incoming staff should be mentioned. These details are not necessary to other staffs like the non-medical staffs whose training will be simpler and specific medical terms is not necessary for them because they don’t see patients directly. The trainings should be conducted within a period of three months. The funds and other resources for the training should be met by the Hospital. The Hospital management should also conduct a short survey to indentify members of staff who have communication skills and practice them during their work. The identified staffs should be given responsibility to champion proper communication within the Hospital and using themselves as examples to their colleagues. It has been found that people tend to listen more to their own colleagues who practice certain ideologies as opposed to an outsider who only mention ideologies and no one can prove that he practices the same. A larger percentage of people learn more through seeing as opposed to listening (Ashworth, 2000).
Regarding the Hierarchy and disrespect concerns, Sacred Heart Hospital should conduct team building among her staff. These kinds of trainings should be in mixed groups. Doctors should not be placed in the same group as nurses and other profession. The training can also be rolled out in phases in period of three months to avoid staff shortage at the facility. This will give the staff of the Hospital and opportunity to interact and develop friendship. Once members of staff have a friendly view of one another it is unlikely that they will disrespect one other even when another is a consultant and the other is a midwife –nurse. Human beings are said to have emotional and non-emotional side. The non-emotional side is always strict to the rules and procedures even when it is not necessary. For instance the Hospital manual say the Consultant makes the overall decision of what needs to be done to a patient. But that doesn’t mean the consultant should be dismissive of observation being made by his/her junior colleagues. The emotional side has friendship part and if the staff can connect on this from then the issue of disrespect will not arise and the all staff will work as a team. The cost for the training should be met by the Hospital (Brown, 1954).
Hygiene is a very crucial component of any medical facility. This paper recommends that All Doctors and nurses should be informed to ensure that they wash their hands and change gloves every time the same is required as guided by the rules and procedures. This should be done through the heads of department and in-charges and can be also be emphasized through the internal memos. This step doesn’t require any significant or extra funding as it is a matter of communicating the instructions to the intended group. The Hospital should implement this recommendation immediately (Gawande, n.d.).
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