Analyzing the Risk Management Failure of Florida Hospital

Overview of the Incident

The purpose of this report is to analyze the risk management failure of Florida Hospital that caused the safety and health issues. This paper also includes the approach of risk management by the hospital through the application of relevant literature, theory, concepts, and legislation. Florida’s Calhoun Liberty hospital had failed in risk management which resulted to the death of a patient named Dawson, the patient died outside the hospital when he was forcibly removed from the emergency department. The scarcity of doctors has generated a high volume of error, such as the inconvenience of patients when medications have been wrongly prescribed by a nurse. All these incidents reflect poor management of risk and a lack of effective clinical governance. In response to the casualties, the healthcare administration agency has imposed a penalty on hospitals and suggested improving the care and risk management. It has been identified that if hospitals have followed the theories and concept of clinical governance, they could be able to manage these incidents and casualties which could have been prevented. Healthcare firms such as clinics and hospitals have complexities, and several risks for the patients, thus, risk management can help to prevent the damage (Hubbard, 2020). In order to manage the hospital activities and implement a risk assessment, hospital management must follow one of the most effective ISO 31000 standards for risk management. ISO 31000 is the international standard for risk management that provide principles and guidelines (Briš, and Keclíková, 2013).

In the Calhoun Liberty hospital of Florida, risk management has been questioned when state investigation identified that due to the failure of risk management, a patient was forcibly removed from the emergency department. However, the hospital made a corrective action plan that was rejected by the government. The incident began when 57 years old Barbara Dawson had refused to leave the hospital, however, the patient was forcibly removed from the hospital by a police officer. Dawson collapsed and died outside the hospital. The examiner had conducted an autopsy and discovered that she had died due to the blood clot in the lung caused by obesity. The incident had been spread all over Florida and prompted a probe by the Agency for Healthcare Administration (AHCA). Florida’s healthcare administration agency has been in charge of licensing and administrating the health care facilities in the policy planning (Relias Media, 2016).

The secretary of AHCA, Elizabeth Dudek, identified the hospital’s lack of policies and risk management, deficiencies in terms of patient’s safety and rights, poor risk management, and patient’s gradience analysis. The AHCA issued a directive to Calhoun Liberty hospital, for the submission of the report on a correction plan. However, the correction plan was rejected by the AHCA. The AHCA sent a letter to the CEO of the hospital indicating that the hospital’s correction plan does not include the suggested points and includes unreadable pages where the facility had failed to specify various aspects of the correction plan. Hence, the hospital was required to re-submit the correction plan and in case of failure, the hospital will be suspended from the Medicaid program. In response to the letter from AHCA, the hospital took some effective steps and have fired the two nurses involved in the incident (Hatter, 2016).

Reasons for Incident

The two major incidents which occurred in the hospital, including that of patient no.10, Dawson, who was forcibly removed from the hospital and had resulted to her death. The second incident involves a case of patient no. 23, a woman that required pain medication. However, the prescribed medication proved abortive. When both issues were highlighted, the risk manager of the hospital stated although, she was not available when the incidents occurred but was aware of them later on. The investigation identified that the hospital had violated the rules and regulations of the state for emergency services. They have failed to follow the policies on medical screening and examination. It has also been identified that the hospital had failed to implement their incident reporting system for 24 patients, they did not follow the suggestion of AHCA, thereby removing 23 patients from the emergency department. Thus, in accordance to the violation of State Emergency Access Law, they were charged with a fine of $45000 (Relias Media, 2016).

It has been confirmed by the Florida Agency of Health Care Administration that there have been deficiencies in risk management approaches of hospitals, it is also stated that the hospitals did not follow the state’s emergency policies which led to the occurrence of those incidents. By the analysis of the whole incident, it has been confirmed that the hospital’s staff were aware of the state policies and risk management. However, it was not put into practice by the staffs. Also, a lethargic approach from nurses had been observed during the investigation which shows the lack of guidance and management. As a result of the observation carried out, It can been said that the healthcare system is a complex system where adverse events occur and the risk associated with it might lead to the increment of these incidents if it is not been controlled or managed. An adverse event in the health may cause unintended injury, as in the case of Dawson where hospital staff did not expect that by removing her from the emergency department would lead to her death. This incident was caused by the hospital management rather than the disease or the illness of the patient. Thus, it is important for a hospital or healthcare firm to follow the procedure of risk management to avoid these incidents. Apart from these incidents patients in hospitals also have the unwilling consequences of treatment and medication.  For example, in the case of patient no. 10 prescribed medicine did not work, a similar situation can be seen in terms of the side effects of medication, however these challenges can be controlled by the appropriate intervention and a comprehensive risk management plan that has been found missing in the case of Calhoun Liberty hospital (Hubbard, 2020).

Risk Assessment During the Incident

One of the main causes of risk management failure was the risk manager, who has not been aware of the incident and was not available. Incidents in healthcare during the care management, interventions, and operational activities cannot be eliminated, however can be controlled or managed by the risk manager using the appropriate risk assessment. Risk management in healthcare refers to the process of planning the management risk, analysis, identification, monitoring the situation, control and response. The purpose of risk management in healthcare is to reduce the impact of adverse events. A study shows that risk management in healthcare can be defined as the approach to reduce the probability that a patient is affected by adverse events (Hubbard, 2020).

The hospital has failed to provide basic care to patients due to failure of risk management. The hospital has maintained the written policies and procedures for emergency services for effective treatment. However, due to it’s poor management of healthcare professionals, the hospital failed to follow the guidelines which resulted to the casualties of two patients, Dawson and patient no. 23. These incidents also confirmed the failure of the hospital in providing proper medical screening, emergency services, and proper discharge of patients. These failures were not related to the limitations of the hospital, however, they are associated to the poor management of clinical governance and risk management in hospital (Hatter, 2016).

The nursing approach in Calhoun Liberty hospital and the unavailability of the risk manager in critical situations shows the lack of management and failure in clinical governance. If the management had proper structured governance, these incidents could have been prevented. Research shows that technological innovation in the biomedical and healthcare sector has supported the organization to implement clinical governance more effectively to ensure the quality of care in the complex environment. Clinical governance is also necessary to manage the risk, and risk management is one the aspect which shows the effectiveness of clinical governance put forward to ensure the best possible care while ensuring the prevention of adverse events (Cagliano, Grimaldi, and Rafele, 2011).

Study shows that similar to the other complex environment, the complexity of healthcare system generates various adverse events if not managed. These adverse events may result in complications, uncertain injuries or disabilities, and or may cause death. Part of the duties of the medical care is that wherever medical service and care are delivered to patients, there is less risk for patients to have complexities and unwilling consequences of treatment. Thus, the probability of errors in medical care cannot be limited, however, effective interventions and management can reduce risks or control the damage. Risk management in healthcare means the planning of risk management including identification, analysis, monitoring, response, and control (Cagliano, Grimaldi, and Rafele, 2011). The other effective way to manage the clinical risk is to work on the errors. Risk prevention in clinical practices requires an understanding of administration, procedure, physical, and individual barriers responsible for the deviation. According to Lucas and Reason’s perspective for error reduction, the methodology requires context analysis, process mapping, risk identification assessment, failure module, and waste analysis. Lucas and Reason’s approach required an analysis of the entire clinical system and barriers that cause adverse events. Ensuring the individual perspective of risk management is one of the most important steps in the methodology to create a background of information for individual healthcare professionals to handle all phases in risk management. This methodology also supports decision-making and its effect on the overall clinical outcome. Decision-making must be effective in healthcare organizations to ensure the absence of negative consequences (Cagliano, Grimaldi, and Rafele, 2011).

Risk Management Approaches That Could Have Prevented the Incident

As the responsibility of risk management lies on the organization and governance system, thus, it is important for healthcare organizations to have highly qualified managers to implement and develop the risk management plans with an aim to reduce exposure. In the key priorities of healthcare organizations, risk management is important not only from the patient’s perspective but also important from the perspective of the organization, as risk management ensures effective and satisfactory treatment (Card and Klein, 2016). It has been observed that dedicated risk managers are essential while setting up a better prevention plan. In the case of Calhoun Liberty, the hospital’s risk manager was not available when the above incidents took place. If the risk manager was available, these incidents could have been prevented as risk managers are responsible for patient’s safety, following legislation and laws regarding patient’s care, removal or reduction of potential medical error, and planning according to the policies (Liu, 2019). It has been observed that healthcare risk management programs are based on ongoing researches. Thus, the risk managers must be active and up to date with relevant details and information about these researches to apply research evidence into the practice to prevent risk in complex environments. For example, recent research has identified that increasing the sleep of healthcare workers residing in the teaching hospital increases the risk and compromises patient safety. Thus, the result and recommendation of this research can be effective to prevent future risks (The University of Scranton, 2021).

Training and guidance are necessary for better risk management. This is a responsibility of the organization and the whole supporting staff including doctors and nurses. Research shows that ISO 31000 framework is an effective training tool that provides guidance to risk management. Managers and healthcare organizations who aim for high-quality risk management in their organization must utilize the ISO 31000 model. This framework is based on the following activities which are; establishing the context, risk identification, risk analysis, evaluation of risk, and risk treatment. ISO 31000 is an international standard published in 2009 that can be effective in various organizations rather than focusing on a specific issues on how to manage risk, the framework remains at a generic level. The standard has a huge vocabulary and concepts to address risk management (Ferdosi, Rezayatmand, and Taleghani, 2020). In addition, ISO 31000 provides principles and guidelines to undertake the critical review of an organization’s risk management process. It helps to identify the possibilities of achieving organizational objective before attempting to control the risk. The ISO 31000 standard consists of a number of principles that needs verification from risk management; creating and protection of value, it is based on the best evidence-based information, it brings responsive changes, it helps to facilitate the continuous improvement in an organization (Risk Engineering, 2017).

Risk management in healthcare ensures patients' safety by multiple approaches and interventions based on the models and researches on risk management. However, the process of risk management can be influenced by various factors including data, personal information, and legislation. The rules and laws passed each year for patient safety may have a huge impact on healthcare organizations and their risk management approaches. Thus, organizations require new techniques and strategies to comply with the new legislation while ensuring effective care for the patients (Malovecka et al., 2015). For example, in the case of Calhoun Liberty hospital, they violated the State Emergency Access Laws by removing Dawson forcibly from the emergency ward (Relias Media, 2016). The government’s policies, rules, and legislation have a huge impact on clinical practices. The need to ensure the delivery of care and services must be performed according to the rules and regulations to avoid illegal actions. For example, according to the Mental health act of 1983 code of practice given by the government of the United Kingdom, it is written that ‘all healthcare organizations must follow the rules while delivering mental health services’. These regulations also ensures patients safety and security (Department of Health, 2013).

Conclusion

Based on the above report, it can be concluded that risk management is the assessment of problems that causes risk, damage, or casualties in  healthcare that also affects the healthcare organization. Thus, it is the responsibility of healthcare organizations to have effective risk management plans to hire such managers who can contribute to bringing effectiveness to risk prevention plans. The above case study suggested that failure of clinical governance led to poor risk management which resulted to the death of Dawson who died when removed forcibly from the emergency department. The incident took place in the absence of the risk manager. However, other nurses and hospital staffs have also shown a lethargic approach. After this incident, another case relating to poor risk management also occurred. Risk management is important to reduce the risk for patients with complexities in hospitals. There are various risk management plans based on the theories and research, however, a risk manager must be up to date with this research as they have the recent evidence. The study shows that one of the effective risk management models for health is the ISO 31000 model which includes the analysis of the entire process and provides required strategies. It is also one of the effective training tools for risk assessment.