Organizational Culture Clues in Adverse Events and Lessons for Management

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 Clues in Adverse Events and Lessons for Management

Introduction

Organizational culture plays a pivotal role in shaping the behavior and decision-making of individuals within a workplace. In this essay, we will analyze two scenarios from Exercise 5.2 and hypothesize the cultural characteristics that may have contributed to the mistakes. Furthermore, we will discuss appropriate results for the individuals involved in the adverse events and the lessons these scenarios offer for departmental management.

Scenario 1: Transport Staff Member Mistakenly Tries to Restrain Patient

Hypothesized Cultural Characteristics:
The cultural characteristics in this scenario suggest a workplace environment that values immediate action and “pitching in” to help without proper training or authorization. There appears to be a lack of clear procedures and communication channels, leading to the staff member taking matters into his own hands. This indicates a culture where individual initiative is prioritized over adherence to established protocols.

Appropriate Results

The transport staff member should be held accountable for his actions, as he ignored proper procedures and lacked the training to handle combative patients. However, it is essential for the organization to acknowledge any underlying cultural issues that may have contributed to his decision. Disciplinary action, combined with additional training and fostering a culture of seeking appropriate assistance, would be appropriate.

Lessons for Management

This scenario highlights the importance of promoting a culture where safety and adherence to protocols take precedence over impromptu actions. Providing proper training to all staff members, encouraging communication between different departments, and establishing clear guidelines for handling challenging situations can mitigate such incidents in the future.

Scenario 3: Nurse Mistakenly Omits Double-Check

Hypothesized Cultural Characteristics

The culture in this scenario may lean towards task-oriented efficiency, where nurses may feel pressured to complete their duties promptly. The inability to find another nurse for the double-check step could indicate a lack of emphasis on teamwork and mutual support in the workplace. Moreover, it might suggest that reporting concerns or seeking help is not fully encouraged or prioritized.

Appropriate Results

While the nurse’s omission of the double-check step is a grave error, it is essential to consider the cultural factors contributing to this mistake. Immediate retraining and education on the significance of the double-check process are crucial. Additionally, fostering a culture that encourages open communication, teamwork, and reporting concerns without fear of reprisals can prevent similar incidents in the future.

Lessons for Management

This scenario highlights the importance of fostering a culture that values patient safety above all else. Management should focus on creating an environment where nurses feel comfortable seeking assistance and reporting potential issues without facing negative consequences. Implementing systems that ensure adequate staffing levels and support for nurses can help prevent future medication errors.

Conclusion

Organizational culture acts as the underlying soil in which management techniques and individual actions prosper or falter. Analyzing the cultural characteristics in scenarios involving adverse events offers valuable insights for departmental management. By addressing the root causes of these mistakes and implementing corrective actions, organizations can cultivate a culture of safety, collaboration, and adherence to protocols, ultimately improving patient outcomes and staff performance.