Organizational Culture and Its Impact on Adverse Events: Lessons from Two Scenarios

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?

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ANSWER

Organizational Culture and Its Impact on Adverse Events: Lessons from Two Scenarios

Introduction

Organizational culture plays a pivotal role in shaping the behavior and decision-making of individuals within a workplace. In this essay, we will explore two scenarios from Exercise 5.2 and analyze potential cultural characteristics that contributed to the occurrence of these adverse events. Additionally, we will discuss appropriate outcomes for the individuals responsible for the mistakes and the lessons they offer to department managers.

Case 1: Transport Staff Member Mistakenly Tries to Restrain Patient

Hypothesized Organizational Culture

The cultural characteristics in this scenario may include a lack of clear communication and hierarchy, a tendency towards impromptu decision-making, and a willingness to “pitch in” without proper training. It is likely that the organization fosters an environment where employees feel compelled to act on their own without seeking proper authorization, which could be attributed to an absence of well-defined protocols and procedures.

Appropriate Results for the Individual

While the staff member acted with good intentions, the use of physical force without appropriate training resulted in harm to the patient. The staff member should be held accountable for their actions and undergo retraining on proper patient restraint procedures. Additionally, the organization should address the lack of training and communication channels to prevent similar incidents in the future.

Lessons and Actions for Department Managers

This scenario emphasizes the importance of clear protocols for handling critical situations, especially when patient safety is at risk. Department managers must ensure that all staff members receive proper training and know when to seek assistance from specialized personnel. Encouraging open communication channels and a culture that values teamwork will reduce the likelihood of impromptu actions that may lead to adverse events.

Case 3: Nurse Mistakenly Omits Double-Check

Hypothesized Organizational Culture

The organizational culture in this scenario may prioritize efficiency over safety, leading to time constraints that hinder adherence to critical protocols. The nurse’s inability to find another colleague for the double-check may indicate a lack of teamwork and peer support within the department. This culture of haste and oversight might be fueled by pressures to meet tight schedules and reduce waiting times for patients.

Appropriate Results for the Individual

While the nurse made an unintentional error, patient safety remains paramount. The nurse should be counseled about the significance of double-checking medication administration and reminded of the importance of following hospital policies. Additionally, the department should investigate systemic issues that hinder proper peer support and consider implementing measures to ensure adherence to safety protocols.

Lessons and Actions for Department Managers

This scenario highlights the critical role of organizational culture in shaping individual behavior and decision-making. Department managers must foster a culture that prioritizes patient safety and encourages adherence to protocols even in high-pressure situations. Implementing strategies to streamline processes and provide support for staff, such as ensuring adequate staffing levels, can help prevent such errors and create a more positive and safety-focused culture.

Conclusion

Organizational culture acts as the foundation upon which management techniques prosper or fail. By analyzing the two scenarios presented, we can see how cultural characteristics significantly influence individual actions and decisions. Addressing cultural issues and emphasizing patient safety will not only improve outcomes for individuals involved in adverse events but also contribute to a safer and more efficient healthcare environment.