Introduction
There are errors and hazards in care that may be part of the system and therefore unnoticed and unseen by hospital staff and management for years. No one knew that a serious flaw in the system existed up until extraordinary events happen in succession and thereby exposing the said weakness of the organization (Rubenfeld et al., 2010, p.115). In many cases, the failure leads to the death of a patient. There is therefore the need for the organization to examine the system and then recommend changes. However, nothing can be done without looking at the root cause of the problem. In the case that will be analyzed below the problem centered on a misunderstanding of their sedation policy.
Errors and Hazards in Care
In one hospital one patient died because of events that the hospital staff and health providers were unable to foresee. The patient had a minor accident and seriously injured his leg. He had to be sedated to perform a procedure to treat a minor fracture in his leg. However, the patient failed to tell the hospital and the nurses that he is on some form of medication. This interfered with some of the treatment applied to him. In the hospital where he was first admitted the staff failed to implement a moderate sedation policy because the one who administered the drug did not see all the factors that were related to the case. One of the major features of the policy was to require technicians and nurses to make sure that the patient remains conscious all throughout the procedure and until he or she is discharged from the hospital.
Aside from this rule, there is also a secondary policy that says the patient must be in continuous B/P, ECG, and pulse oximeter throughout the sedation process (McClain, 2001, p.1). There is also a clear directive that these steps must be followed to the letter and the patient should be monitored up until discharge from the said institution. But in this case, the ECG monitor was never used. This device should have functioned as a mechanism that warns the nurses that there is something wrong with the patient. The patient suffered ventricular fibrillation and as a consequence, he suffered brain death seven days later.
Root Cause?
The first thing that has to be analyzed is the fact that no supplemental oxygen was given when the O2 saturation alarm gave a clear warning that oxygen saturation was low. The failure to administer supplemental oxygen should not be blamed on the nurse on duty. It can be attributed however to the inadequacies of the sedation policy. The policy clearly stated that the nurse must administer continuous ECG, blood pressure monitor as well as pulse oximeter but there was no mention of supplemental oxygen. Thus, the nurse was not required to give oxygen even when it was the most logical thing to do considering the situation.
It must also be made clear that the patient lost consciousness because of the interaction of his medication and the sedative drug applied. The physician was forced to increase the dosage because there was no anesthetic effect, meaning the person could still feel the pain and therefore the staff cannot perform the treatment required to heal the fracture in his leg. The problems that arose from these actions revealed that there are certain scenarios and factors that the health workers were unable to anticipate and as a result, they were unable to plan ahead for contingencies.
The pain killer medicines such as atorvastatin and oxycodone reacted with the sedative drug that was used. Investigators also have to consider the fact that the patient weighed as much as 175 pounds and that he has elevated cholesterol and lipids. The physician and the nurses were unable to factor all of these into the treatment process.
Another major aspect of the case that has to be analyzed is the fact that when the oxygen levels were low there was no one of appropriate rank and experience who could have intervened the moment the alarm went off. The nurse who was supposed to have understood the gravity of the situation was not in the room when the patient’s blood pressure dropped to low levels. The unavailability of the nurse can be traced to another unforeseen problem. In that particular time period there was a sudden increase in the number of patients admitted to the hospital.
If no one took the time to get to the root cause of the problem then it is very easy to lay all the blame on the nurses and the physicians responsible for the health of the patient. But a closer examination of the facts must prompt the hospital management to revise their policies and develop a system that can help deal with the sudden upsurge in the number of patients admitted to the hospital.
Applying Change
Hospital staff and management can easily become defensive and may not accept the need to change a part of their system (Schulte, 2007, p.1). The predictable response is to reprimand the nurses and the only physician on duty. Hospital management may suddenly develop certain defense mechanisms to evade the backlash from regulatory agencies and even the general public. Thus, it is important for them to know that there are multiple factors to consider and that no one should blame them for everything that has happened to the patient.
If the hospital management is willing to go beyond the blame game then the organization can advance to the next level. The next phase of the process is the admission that change is needed. After crossing this threshold, staff and management can demonstrate an open mind and acknowledge the need to improve their current system.
After crossing this particular threshold the organization is willing to go through training. In the training phase the organization is willing to learn new techniques. This is an important step because the hospital needed to improve their triage system as well as the management of ongoing treatment procedures. By doing so, nurses and physicians are given the necessary tools that enable them to access pertinent information even in simple cases such as a fractured leg.
Aside from treatment procedures, hospital management must look into the problem with inadequate number of hospital personnel when there is a sudden upsurge in the number of patients admitted to the hospital. The organization must carefully prepare for contingencies and when this problem arises they must know what to do. One of the things that they can do is to develop a system wherein off-duty personnel can be contacted at a moment’s notice.
Nurses and physicians resting that day can be called up anytime and can be expected to arrive at the hospital as soon as possible. This can prevent burnout and health workers can focus on their jobs and not be overwhelmed. Thus, errors and hazards can be avoided.
In addition the staff must undergo a re-training of the new sedation policy. The nurses must be trained to adhere to a strict protocol. There must be no sudden changes in the dosage of the anesthesia that will be used on any given case. If there is a need to increase dosage it must immediately alert nurse and physician that there must be something about the case that they overlooked.
Using Technology
It is to their advantage if they will leverage technology to improve the overall system. Information technology must be carefully studied to determine which one is applicable to their current situation. The information that they gathered through the triage must be faithfully transmitted to the nurses and physician assigned to the said patient. One way to deal with this need is to use digital technology so that data is not lost and sent immediately to the computer or handheld devices of the physician and head nurse.
Before going any further it is important to choose the right people that must take part in the evaluation. These personnel must not only be capable but in the position to see the big picture so to speak. Administrators, physicians and nurses must be included in the committee that will affect change. Their inputs must be valued in order for the change agent to develop a new system that can help the hospital deal with extraordinary events and weed out flaws in the system before any untoward incident can happen in the future.
Role of Nurses
Nurses play a key role in the hospital and their contribution must not be taken for granted. A nurse is one of the first people that a patient will see before being admitted to the hospital. In the triage phase of the treatment process nurses are there to assist. An ill-equipped nurse lacking training can do more damage. A nurse that does not understand the significance of his or her role can be a liability in the organization. It is important to know their needs and the limitations that they bring to the job.
Training is needed. An upgraded system must be designed with the role of the nurse in consideration. In the aforementioned case one of the major weaknesses is the lack of communication. Nurses must have the capability to receive all the pertinent information regarding the case. More importantly nurses must be given the capability to communicate to their superiors. A nurse must not feel threatened or insecure by the need to express doubts and hesitation regarding the extraordinary events that surround a particular case.
Conclusion
The death of the patient is something that could have easily been avoided if the correct system was in place. But the absence of protocols that could correctly provide a clear course of action is the reason why the hospital was overwhelmed by problems and as a result caused the death of a patient. There is a need to acknowledge the flaws in the system in order to begin the process of change towards the goal of organizational responsibility.
References
McClain, B. (2001). Clinical Administrative Policy and Procedure Manual. Web.
Rubenfeld, et al. (2010). Critical Thinking for Nurses: Achieving the IOM Competence. MA: Jones and Bartlett Publishers.
Schulte, S. (2007). Avoiding Culture Shock: Using Behavior Change Theory to Implement Quality Improvement Programs.