The board and CEO of a hospital are very important to the implementation of patient safety protocols. They are accountable for everyone underneath them in the hospital hierarchy. “Leaders are responsible for everything in the organization, especially everything that goes wrong.” This quote was given by Paul O’Neill in our text. (Youngberg, 2011, pg. 91). This is a very bold and honest statement by such a high up person within an organization. He seems like he would value transparency and accountability. The CEO and board members are responsible for all of the patient safety protocols that are in place in a hospital organization. They are also the ones held to the highest quality standards with an organization, especially the CEO. In the video, it reveals many terrifying stats as far as deaths outside a hospital setting and inside. “One in every five hundred people admitted to a hospital in the U.S. is killed my a medical error. “Five percent of pediatric medications are ordered wrong.” This is especially scary due to “children having three times the chance of having an adverse reaction to drugs.” (“Are You Safe? (Patient Safety Video)”, 2019). No matter how much education is supposed to be conducted within a hospital, sometimes knowledge is your best protection, as a patient you need to research for yourself before you go in for a doctor’s visit or go to the hospital (except in emergent situations, obviously). As a patient, understanding the procedure to be done and understanding all the medications one might receive are also important things to become familiar with. Finally, I think the best thing you can do as a patient, is ask questions, no question is too dumb to ask when it comes to your health. (“Are You Safe? (Patient Safety Video)”, 2019).
The role of the CEO, the board members and the risk management team, when it comes to the education of physicians in patient safety is to develop a curriculum in which physicians feel engaged to participate in patient safety, have them identify with the concepts, and have them acquire the knowledge into their own care/practice. The teachings must be seen as applicable to real life situations. (Youngberg, 2011, pg. 381). A study by Kolb and Kolb revealed that when a person is learning they often retain more when actively participating in a process. They also acquire a greater ability to transfer this new information into different situations. The learning environment should also be stimulating but safe, so they do not feel like they are being humiliated in any way that they participate. (Youngberg, 2011, pg. 381-383).
“To effectively understand and manage medical errors and contribute to the improvement of health care delivery systems, a patient safety curriculum for physicians should include:
- The history and background of patient safety – an overview of the modern patient safety movement since the early 1990’s, To Err is Human to show just how prevalent and scary medical errors can be, yet preventable.
- The culture of medicine and medical education – a review of the physician’s role in patient safety and quality improvement and the culture of medicine with a focus on tradition, medical education and medical-practice structures.
- System-based theories – Swiss cheese model, Hindsight-Bias theory, Root-Cause Analysis, Failure-Mode-and-Effect analysis.
- Quality Improvement – Measurement of quality – measure the structure, process and outcome to effectively evaluate quality in health care as outlined by Avedis Donabedian. Identifying and defining quality quality issues, quality-improvement tools, understanding and effectively using data and leading a team to improve quality may all be aspects of this particular part of the curriculum.
- Communication – Physician/patient communication, informed consent, disclosure, hand offs, and team training.
- Interdisciplinary teamwork – Kind of the same as team training but between all departments.
- Organizational and community demand for safer patient care – surveys throughout the community on how they view patient safety and policies.
- Application of patient safety and quality-improvement theory, tools, and initiatives in clinical practice – example: National Coordinating Council for Medication Error Reporting and Prevention, an independent body that comprises 24 national healthcare organizations, which are collaborating to address the interdisciplinary causes of errors and to promote the safe use of medications. The initiative recommendations to reduce medication errors. (Youngberg, 2011, pg. 391).
- Liability exposure and legal actions that may arise from patient injuries – Incident reporting, investigations into adverse reactions/events, and patient complaints should be evaluated.” (Youngberg, 2011, pg. 383-384).
Hospital Nightmare/Failure to Obtain Consent
As stated earlier, the CEO and board members, but mainly the CEO have all the responsibility of putting into place a strong curriculum that promotes the best of patient safety. These two entities should implement effective and accountable quality-improvement and patient safety systems. Some ways to make sure good quality is met with board members is by evaluating patient satisfaction scores, at least annually. Also, the board and medical staff should be responsible for setting the agenda in board meetings. These are just a few ways to help with quality improvement. (Youngberg, 2011, pg. 98-99).
In the hospital nightmare scenario, a doctor was found to have used the same gloves to inspect several patients in a OR recovery room. As the doctor went to the next room to see the next patient he never once changed his gloves or washed his hands. The very first patient he evaluated has a dormant Staph infection. So, as he went from patient to patient he was spreading that deadly infection to them all. The last patient had the most severe case and, unfortunately, this may have all been preventable through simple hand hygiene and changing of gloves. The doctor and hospital could be liable to losses in this case. The doctor and nurse that were interviewed in this simulation both agreed that proper training/education needed to be done and also stated that, prior to this incident, not many signs were hung up to help remind employees of many hospital policies. So, patient safety in this case was very important, the infection the patient suffered could have been deadly. It’s obvious to see how the mistakes made here could have been avoided and directly affected the patient’s safety.
In the failure to obtain consent scenario, the doctor had met with a patient about getting a cardiac catheterization done and it was to include stents. The patient did not want the stents however, especially after talking over the CT results with the radiologist. She made him feel like his condition was not as bad as many of the other cases that actually needed stent placements. When his written consent form was handed to him he even took the time to cross out the parts about his stents, yet no follow up with him was made. The doctor said he had a conversation with the patient after that consent had been signed and he seemed okay with the stents at that time. In order to provide better patient safety, the doctor should have followed up with the patient prior to the surgery day to make sure they were both on the same page. If he did in fact have a conversation with the patient after the first written consent he should have made another form to confirm the verbal consent. The written consent was all that was on file so, again, the hospital was liable here. If a court case was held, the written consent would always win over a verbal consent, if not documented. The patient specifically did not want something placed in his body and it was done anyway, this is a huge breach of his safety. Education in informed consent is a must by the CEO, board and all leadership positions.
Are You Safe? (Patient Safety Video). (2019). Retrieved from https://www.youtube.com/watch?v=BFd54Yzg-vo&feature=youtu.be
Youngberg, B. (2011). Principles of risk management and patient safety. Sudbury, MA: Jones and Bartlett Publishers.
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