Organizational Culture and Equitable Results in Adverse Events

QUESTION

Exercise 5.2 Objective: To apply equitable results for individuals involved in an adverse event. Instructions: Read the following four case studies. Determine the appropriate results for the individual who made the mistake. Case 1: Transport Staff Member Mistakenly Tries to Restrain Patient A patient transport staff member is passing the psychiatric unit and notices a nurse struggling with a confused and argumentative patient who was trying to leave the unit. The transporter tries to restrain the patient, but he seizes the patient roughly and fractures several of the patient’s ribs. The transporter real-ized he had breached procedures as the nurse had not asked for assistance and nobody appeared to be in immediate physical danger; he also had no training in handling combative patients. He admits to his supervisor that he had simply decided to “pitch in” and help.

Case 2: Housekeeper Mistakenly Overlooks Posting a Wet-Floor Sign A housekeeper is waxing the floors near the hospital cafeteria at 1 a.m. He cannot find a wet-floor sign and would have had to go back to the office to find one. He believes there will not be any foot traffic in the area at this time of night, so he does not go to the trouble of finding a sign. He leaves to take his mid-shift break while the floor dries. A young patient who could not sleep walks with his mother near the vending machine and slips on the wet floor, breaking his wrist. The housekeeping staff often have to search for wet-floor signs, which causes them to get behind in their work. Although the manager is aware of this problem, no additional signs have yet to be purchased.

Case 3: Nurse Mistakenly Omits Double-Check A nurse is getting ready to administer a high dose of insulin. Consistent with hospital policy, she looks for another nurse to review her calculation and the amount in the syringe vial, prior to administration. She is unable to find another nurse and fails to perform the double-check step. The patient receives an over-dose of insulin, which results in complications requiring transfer to the ICU.

Case 4: Therapist Mistakenly Ignores Alarm Bell A confused patient in a geriatric care unit wanders down the hall and goes out the fire door. The alarm bell sounds but the physical therapist walking down the hall just ignores it, thinking that it’s just another false alarm. The patient is later found outside lying on the ground after falling and breaking a hip.

Chapter 5 of your textbook discusses organizational culture,...
Chapter 5 of your textbook discusses organizational culture, calling it the ‘soil,’ in which the ‘seeds’ (management techniques) can prosper (p. 80). For this week’s discussion, you are encouraged to take 2 of the 4 scenarios presented in Exercise 5.2 (p. 80) and evaluate them for potential clues to the organizational culture they occur in.

For your two scenarios, discuss the following: What do you hypothesize are some of the cultural characteristics the scenario occurred in and why? What are the appropriate results for the individual who made the mistake? If you managed the department the mistake occurred in, what lessons does this scenario offer you, and what actions do you either learn more about or correct the issues?

please provide reference for sources

ANSWER

Organizational Culture and Equitable Results in Adverse Events

Introduction

Organizational culture plays a crucial role in shaping the behavior and decision-making of individuals within a workplace. In this discussion, we will analyze two of the scenarios presented in Exercise 5.2, focusing on the potential cultural characteristics that influenced the mistakes and the appropriate results for the individuals involved. Additionally, we will explore the lessons each scenario offers and the actions that can be taken to improve the department’s practices.

Scenario 1: Transport Staff Member Mistakenly Tries to Restrain Patient

Hypothesized Cultural Characteristics

The culture in this scenario may be characterized by a sense of urgency and a willingness to take action without proper authorization or training. There could be an inclination towards informal problem-solving, where individuals feel empowered to intervene in critical situations without following established procedures. The culture might also lack a clear emphasis on the importance of proper training and adherence to protocols when dealing with challenging situations.

Appropriate Results for the Individual

While the staff member acted with good intentions, the fact remains that he caused harm to the patient due to his lack of training and unauthorized intervention. An equitable approach would involve a thorough investigation into the incident, understanding the context and motivations behind the staff member’s actions. A disciplinary action may be warranted to emphasize the importance of following protocols and seeking assistance when necessary. Simultaneously, the organization should provide training on handling combative patients to prevent such incidents in the future.

Lessons and Actions

As a manager, this scenario highlights the need for a robust training program that equips staff with the necessary skills to handle complex situations. Additionally, promoting a culture of open communication and encouraging staff to seek help when required can prevent unauthorized interventions. Regular reviews of protocols and their effectiveness should be conducted, and if needed, adjustments should be made to improve patient safety and staff performance.

Scenario 3: Nurse Mistakenly Omits Double-Check

Hypothesized Cultural Characteristics

The culture in this scenario may be characterized by time pressures and a lack of emphasis on the importance of double-checking procedures. There might be a perception that seeking assistance for a routine task is an inconvenience, leading to a reluctance to follow protocols when time is limited. Additionally, there could be a lack of proper supervision or support for nurses, making it challenging to adhere to all established safety procedures consistently.

Appropriate Results for the Individual

The nurse’s omission of the double-check step resulted in a serious medical complication for the patient. An equitable approach would involve a thorough investigation to understand the circumstances that led to the mistake. If the investigation reveals systemic issues such as insufficient staffing or unrealistic time constraints, these factors should be taken into consideration while determining appropriate consequences. The nurse may need additional training and support, and the organization should review its staffing and workload management practices to ensure patient safety.

Lessons and Actions

As a manager, this scenario underscores the significance of a patient safety-oriented culture. Emphasizing the importance of following protocols and providing adequate resources to support staff in their tasks can prevent such errors. Implementing regular training sessions and reminders about critical safety steps can reinforce good practices. Additionally, fostering an environment where nurses feel comfortable seeking assistance without fear of retribution can further enhance patient safety.

Conclusion

Organizational culture has a profound impact on individual behavior and decision-making within a workplace. By evaluating the scenarios and considering their cultural characteristics, we can identify potential areas for improvement. Adopting equitable approaches in addressing mistakes ensures that individuals are held accountable while taking into account contextual factors. By learning from these scenarios and implementing appropriate actions, departments can foster a culture of safety, open communication, and continuous improvement, ultimately benefiting both staff and patients.