Patient Safety: An Overview of the Risk and Protection Factors - Essay Sample

Introduction

According to the World Health Organization, Patient safety is the nonattendance of preventable dangers to a patient during the procedure of medicinal services and the decrease of the threat of high degree damage related to social insurance to a satisfactory least. An adequate level of safety alludes to the aggregate ideas of given current information, assets accessible, and the setting in which care was conveyed against the danger of non-treatment or other treatment. When discussing understanding safety, there is a genuine discussion about how emergency clinics and other social insurance associations shield their patients from blunders, wounds, mishaps, and diseases (Vincent 2006). While numerous clinics are great at protecting their patients from any danger, a few medical clinics are bad at the same. Such a significant number of individuals die consistently from preventable mistakes in emergency clinics. It is dependent upon everybody to ensure that patient safety is the main need at each emergency clinic over the United States (Vincent 2011). A few medical clinics have concealed threats, yet there are things you can do to ensure yourself and your friends and family. Patient safety policies are the policies which are responsible for reducing the peril of adversarial effects associated with various medical care across a variety of conditions and diagnoses.

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The case study about Wayne Jowett provides the best chance to examine the seven steps of patient safety practices. These steps are very relevant to the development of such factors as the operational practices that involve due diligence by the nurses, such as checking the syringe condition and drug solution status. The second step is the creation of a proper protocol that guides the decisions of the professionals to ensure that there is a limited error in the administration process. The administration is very vital; the death of Jowett arose from the erroneous administration of vincristine drugs (Amelberti et al. 2005, p 767). The administration also includes such aspects as the labelling and packaging. Training and communication are also critical aspects of patient safety practices, and the final is the technical aspects and national issues that include administrative factors.

Learning Errors

Healthcare errors are the disappointments of arranged activities to be finished as expected or the utilization of an off-base intending to accomplish a point (Beckett and Kipnis 2009, p 20). Among the issues that generally happen throughout giving human services are harsh medication occasions and ill-advised transfusions, bad wounds, and wrong-site medical procedures, suicides, limitation related wounds or demise, falls, consumes, pressure ulcers, and mixed up quiet characters. High error rates with genuine outcomes are well on the way to happen in concentrated healthcare units, working rooms, and crisis divisions. Past their expense in human lives, preventable therapeutic blunders accurate other huge tolls (McNab et al. 2016, p 443). The learning errors occur through the case study about Wayne Jowett. The patient died from an erroneous injection with Vincristine through the intrathecal route which is fatal. The efforts to undo the error were all futile. The death of Mr Jowett is yet one f the many cases that point to the sensitivities that surround the medical mistakes that should not be overlooked (Rooney and Heuvel, 2004, p 53). The case that happened at ward E17 meant for the cancer patients is an eye opponent to the keenness in the treatments in the healthcare sectors in mitigating the errors in the patient care exercise. There is a need for the entire society to ensure that they reduce and control the effects that may arise from the understanding of the work environment by those who are involved in the whole exercise (Wachter 2007).

Background Study

The history of effective patient care is long. There are several cases in mention that point to the fact that slight neglect on healthcare practices leads to a devastating effect that can claim the lives of re patient if not acted on time. The case study surrounding Wayne Jowett points towards the need to have care and diligence in the healthcare sector for the benefit of the patients that are involved. Wayne Jowett's case was a simple case of medical error that led to the death of a somewhat fragile patient that was on his way to recovery (Hughes et al. 2009, p22). The fishbone analysis used to unearth the root cause analysis (RCA) that helped in realizing the dangers involved in the whole of Jowett's case.

Root Cause Analysis (RCA)

Wayne Jowett's case provides a clear manifestation of the need by the entire society to consider and understand the need for the various organizational factors that play a vital role in the management crisis in the organization (Percarpio et al. 2008, p 392). The use of high reliability in the organizational approach is one of the most effective ways to ensure that that runs by a mindful-leadership approach (Singer et al. 2009, p 308). Jowett's root cause analysis provides a chance for the inclusion of some of the very critical aspects that can appear from the whole process.

Team Work

A team treated Mr Jowett of specialized doctors. His cancer condition was on advanced stages and, as such, required a well-coordinated approach in ensuring that all gaps in the treatment plan ended. His treatment consisted of getting Vincristine and oral Prednisolone every three months. The drug administration came on top of the treatment of intrathecal Cytosine, which was meant to stabilize his condition. The team of doctors included Dr Musuka, who administered chemotherapy to the patient. In a healthcare organization, teamwork is essential between the nursing team as well as the doctors; the team of doctors that took care of him since 2001, when he began receiving treatment at the daycare.

The teamwork between the healthcare specialists must be well-coordinated and smoothly run to ensure that there is complete avoidance of any errors that may arise. The placement of Mr Wayne Jowett in a ward that had a total f 18 beds meant that there was specialized care with the team o nurses for timely care. However, this is where the error occurred (Wu et al. 2008, p. 686). The criticality of Jowett's condition prompted the doctors to administer successive drugs, which would end up being fatal in the long run. The consultant visits in the wards daily were to ensure that there was a constant update on the conditions of the patients and to ensure that every change noted for improvement on the following day. The registered nurses (RNs) were tasked with ensuring that they kept the patients in the best condition available in the entire facility (Katri et al. 2009, p. 309).

The error in this condition has been the medical administration process whereby the patient was given intravenous IV that is best for the control and management of Leukemia. The erroneous administration of this drug to the patient had an almost immediate effect, with the effects immediately evident (Walshe and Boaden 2005). The nurse and the doctors moved in swiftly to mitigate the effect of the same. However, this was not going to be an easy fete as the effect had already devastatingly taken impact on the patient. Te immediate solution was to change the basis upon which Mr Jowett's treatment occurred. The prescription protocol was changed to allow for the drug administration on different days. However, this did not happen, as both drugs were administered at once (Helmreich 2000, p 783). The changing of the labelling, the introduction of the nursing staff to ensure that there is sufficient allowance of the for error reduction in as far as the confusion is concerned. A better solution to patient healthcare would be to introduce a digitalized medical administration system to avert any possible confusion that may arise in the process of treatment (Toft 2001).

Individual

In the root cause analysis process, individuals play a very vital part in the whole process. The patient safety in the healthcare set up has individuals as a very critical component that ensures that everything runs according to plans (Jiang et al. 2016, p 117). It is on such a basis that the entire system must rely on the fundamental aspects such as the ability to relate with the patients and to ensure that they come with the right medication and the establishment of a sufficient condition for the service delivery Singer et al. 2009, p 25). In the case of Jowett, there was a mass failure from many individuals starting from the leadership. In the high-reliability organization setup, there is always a need for mindful leadership that accommodates bottom-up communication, coupled with proactive measures (Perrow 1984). However, according to the case whereby the patient lost his life the individual component of the fishbone, RCA was not well explored.

The specialist registrar is a vital individual in the medical fraternity. The position means to certify and to ensure that all the healthcare providers are persons of qualifications and ones that are best suited for the task. They provide induction and training to all the specialists in running the wards and the process (Walshe and Smith 2006). These registrars are trained on some of the fundamental aspects such as the 'open door' policies that make them accessible for consultation at any time. There are other personalities, such as Day Case coordinators. These are some of the most critical personalities that ensure that there are effective patient safety and healthcare (Waterson 2009, p. 1191).

From Jowett's case, it is clear that the day case coordinator transported the drug from floor B toward E17. However, what is stunning is that they did not receive sufficient communication regarding the dangers that the Vincristine and other drugs for intrathecal use pose dangers when used nearby (Tews et al. 2012, p 371). The lack of communication and efficient coordination is where the gross error emerged. Te involved professional staff, according to the report, were seen to have come a bit too late to salvage the situation. Such personalities as Dr Mulhem, who is a professional physician, also noted the need for supervision by the registrar whenever SHO was providing the chemotherapy to Mr Jowett.

The individual factor, as identified from the fishbone diagram tool of the RCA process, noted such elements as the physical aspects whereby the medical attendants could have suffered from the fatigue and lethargy coming from the Christmas period that most people had attended. The psychological elements such as Dr Musuka prescribing Vincristine administration sequentially with denotation with letter C then D. this by far could have been seen to be one of the areas the led to the errors that led to death (Weick and Sutccliffe 2001).

The solution to the cases of individual-related medical errors is vast. The first aspect is to improve communication and engagement between individuals, the organization, and the entire healthcare sector to ensure that there is no lapse between process and order. There must be a process to ensure that there is a criterion for problem anticipation (Wu, 2000, p.727). Therefore, there must be an investment in resources, both human and technical, to ensure that individual error minimizes in the healthcare sector.

Training and Education

Training and education in the patient safety process involved an elaborate communication process, both verbal and written (Chang et al. 2005, p 95). The senior house officers are meant to come up with clear and well-spelt codes of practice that ensures that every professional in the healthcare follows to avoid instances of miscommunication and confusion that arose in the lead up to Mr Jowett's demise. T...