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The recent patient safety culture survey has given us priceless considerations about our organisation's past, present, and future safety values and

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Added on: 2024-11-12 19:00:16
Order Code: SA Student Renae Medical Sciences Assignment(5_24_42034_52)
Question Task Id: 506373

The recent patient safety culture survey has given us priceless considerations about our organisation's past, present, and future safety values and the general safety culture. Although this study accentuates many areas of the district's strengths, it also exposes the possibility of gaps and weak spots that must be systematically identified and treated by focusing on intervention and leadership commitment.

Three overarching concerns emerge as top priorities from the survey data: 1) safety incidents and near misses are generally not accurately reported; and 2) because of the unwillingness to hold each other accountable, there is the inability of teams to work in close collaboration and communicate effective handoffs efficiently between one hospital unit and another. Often, a reluctance from the staff to openly report any mistakes stems from the lack of a nurturing environment from the leadership because perceptions are that the leadership needs to resolve issues that lead to the prevention of unnecessary incidents and quality of life over time. Failing to do that puts our organisation at risk.

We can incorporate action plans that use safety frameworks like HRO, just culture, and process improvement tools. This multifaceted approach to the problem incorporates the elements of revamping the event reporting system, instilling safe handoffs, and transforming the leadership mindset through training and accountability processes. Sustainable development will be ensured if safety becomes routine and sticks in the institutional setting because that is the principle on which the culture of safety relies.

The survey results manifest a concerning extent of ubiquitous reporting of rare adverse events and close calls in contrast to different hospital units and staff portfolios. Several risky locations, such as the surgery unit and emergency department (surgery unit: 37.5%, emergency department: 33.3%), have said that "rarely" the medical mistakes that patients haven't carried out have been reported to them (survey data). However, compared to ICU, where 75% of the units mentioned they always or most of the time report such close-calls (survey data), and medicine units, where close-call events were reported by 40% of the units most of the time or always (survey data), the reported numbers are like comparing entirely different things.

Even more worrisome, 25% answered zero, meaning that the same share of people didnt use an event report, and another 18.8% filed 21 or higher (Survey Data). This well-marked gulf between the practices and quantity of reporting conveys that there are possible untold instances in which the organisation could have discovered safety conditions and learned from this experience.

Reporting events in depth is regarded as common ground and a basis for enhancing patient safety by almost all experts (Reason, 1997). It represents a powerful tool for businesses that they use to establish the chains of cause and effect behind these adverse events, to design processes that can be implemented to prevent them from happening again, and finally, to create an environment that promotes learning and an open atmosphere of accountability (Boysen, 2013). As the prevalence of underreporting and failures in appropriateness reflect the lack of safety consciousness, behaviour norms, and psychological safety to speak about wrongdoings freely, this situation shows noticeable gaps in safety culture, reporting routines, and psychological safety to discuss mistakes freely.

The main issue, "nowcasting" NIMBY diction, was found to be the last pocket of unhealthy "shame and blame" moves. When employees feel reluctant or incapable of reporting near misses or mistakes without fearing unjust punishment, or they don't want to terminate their careers, such issues remain unaddressed. Thus, there remains a risk of not knowing what is unknown to the people and not being aware of the mistakes or near misses (Reason, 2000). The survey information indicates the Department of Surgery (62.5%), ER (66.7%), and Admin (62.5%) as departments with very high "staff don't feel free to raise questions against their authority." In addition, many people (50%) disagreed that "mistakes are not getting written up as a staff shortcoming" instead of as opportunities to do better (Survey Data). Without adequate reporting and old-school cultural ideas that look for scapegoats and are based on accountability, many learning opportunities will never be recognised.

Showing that some adult hospital units scored comparatively well on survey measures, the data displayed the obvious lack of coordinated teamwork and standardised handoff process within the different stations as a patient moves from one department to the next. Among the suggestions (56.3% disagreed while others (56.3%)), where "units do not coordinate well with each other" was mentioned, the first team and other teams felt there was some form of cooperation between the two (Survey Data). In the same way, 31.3% of responders interviewed expressed the view that there is a problem of "poor cooperation among units that need to work together" (Survey Data).

Innovative healthcare settings face a great challenge as patients are moving across departmental facilities that include several specialties and levels of care. Therefore, the breakdown in communication and the problem in handover can represent the highest rate of adverse events among patients (The Joint Commission, 2017). When admitting patients, critical information can very easily be the most mistake-prone step, whether it be lost, miscommunicated, or read and not verified upon transfer. Which has been thus "left open so the system, made from the individual errors in the underlying processes, [can be] recognised" (Flinchbaugh et al., 2021, p 42).

Yet while the first approach to the problem seems to maximise efficiency within single medical units, the survey data emphasise more the necessity of including the HRO method with broader horizons and points of reference, including entire patient journeys and their multiple coexistent units (Weick & Sutcliffe, 2007). The use of harmonised instruments, unified procedures, and durable handoff techniques is indispensable to repairing gaps in the tunnels through which the wrong procedure can penetrate and lead to preventable cases of harm. The psychological orientation, as well as the building of the foundation for mutual respect, cross-disciplinary understanding, and collective consciousness between the different hospital units, is best developed during training.

The safety culture survey mentioned the working atmosphere issue, including the worker's impression of how management leadership reacts toward mistakes and safety operations. As we know from the beginning, safety psychological to expression, questioning decisions, or reporting concerns from the staff without fear of any punishment are missing -obviously in high-risk areas including Surgery, the Emergency Department, and among the Administration/Management staff (Survey Data).

Furthermore, a humongous amount of 43.8% of all respondents contradicted the idea that leaders always miss out on the existence of recurring safety problems (Survey Data). The lifelong and continuous operation of failed and random process steps is one example of deviant normalisation that could lead to the worst situation quickly (Boysen, 2013). When the personnel sees that the upper echelons deliberately close their eyes to the known safety issues, it has a very powerful discouraging effect that further increases the number of underreported incidents.

In addition, 50% of the staff believes that within the firm or organisation entirely, there isn't a true "blame-free" environment inside which the team members can accept errors as an occasion for growth rather than a situation where persons are reprimanded for doing something wrong. It is like human beings to err, and patient safety experts who have gained experiential knowledge will tell us that a blaming culture of punishment is the cause of higher error rates since professionals fear being caught and will not bring the errors to light. Staff are afraid to voice their opinion regarding the errors due to the fear of being brought into the limelight where their reputation or career could be the worst affected by unforeseeable pockets of silence that promote small process deviations to become big issues in the long run (Frankel et al., 2006).

True security dominance means seeing CEOs at the helm of the organisational culture community of mutual responsibility from the top down. In such cases, fair and just methods must be introduced that would help differentiate the former (human accidental errors, which are covered based on learning cycle and condition revision) from the latter (deliberate unlawful breaches that are treated correspondingly consequent to rule and safeguard presence).

1. Revamp Event Reporting System & Training

Along with the technical and the main points to be considered in the modernisation, systemisation, and de-stigmatisation of the reporting of events throughout the organisation are several tactical steps. Initially, redefining the current reporting system and workflow procedures using Lean process-improving techniques to eliminate friction points, establish straight standard operating procedures in the hospital, and integrate them within all hospital units is essential (Boysen, 2013). Such software could be integrated into the modern event reporting system with a built-in trend identification function to help uncover the pain points.

Along these lines, comprehensive staff training must be developed and delivered to ensure that all sports personalities in this area have a shared understanding of their responsibilities regarding event reporting jobs, categories, and protocols. This training should cover more than just the technical procedural stages; it should also provide extensive education on cultural values, psychological safety, and practising working environment (Frankel et al., 2006). Staff at all levels should depart, understanding that when reporting events (near misses and accidents), they will not report them to get someone to take the blame but as part of working to maintain a stable system with high reliability.

Apart from training competent employees to be sensitive to reported incidents, managers and supervisors should also be trained to take responsibility for mistakes when a staff member makes human errors so that they can be focused on learning and process improvement without any punitive measures (Boysen, 2013). This will allow employees to put such reservations into perspective that they find just write-ups or mistakes will be written up against them.

2. Establish Systems for Cross-Unit Teamwork & Handoffs

In conclusion, the survey results show insufficient coordination and uninterrupted department transitions. There is a need for a few micro approaches based on the principles of high-reliability organisations (HRO) and crew resource management.

First, a complete mapping must be done to document all the critical patient interactions. This will identify whether they are passing through different units, care teams, and clinical disciplines across the health continuum. As the system-related perspective demonstrates the patients transitions with the highest risk of unstandardised and resilient communication and handoff protocols, the indicated scenarios are the significant focus of the communication system.

Through this template, the organisation can initiate the creation of a comprehensive set of standardised communication tools that are also adapted to different situations, for example, in-hospital or one-handed-off. The applications of such methods may involve research-based approaches like these.

The following communication tools can be used: ISBAR protocols, read-back, handoff sheets, and virtual status boards and scorecards (The Joint Commission, 2017). The objectives of these undertakings are ensuring some structured processes that may be used for the correct transmission of paramount information, verifying the information's accuracy, and transferring fundamental care from one unit to another without interruption.

However, on the whole, the resolution of technical problems without using telerobotics equipment will be pointless. The additional aspect will be an in-depth training protocol for all staff who will be performing handoffs, and such training will consider their practical realm and handoff scenarios. This training must extend beyond just the tools and procedures to foster the vital cultural underpinnings of an HRO mindset: the place for expertise, interest in interdisciplinary cooperation, respect for different points of view, understanding of the operation variety and identification of underlying risks (Weick & Sutcliffe, 2007).

Modelling activities in which different units or specialties assist in the transfer could be one option for creating a common mental model. Another significant attention should be given to the practical exercise that would allow medical officers to develop critical handoff skills like synthesising key information, performing a check procedure, using disagreement, and sustaining an inquiry (The Joint Commission, 2017).

3. Embed Just Culture & Safety Leadership

The third pillar of the Action Plan involves undertaking a deep and systematic redefinition of organisational programs on organisational justice and safety-leadership accountability processes. This involves leaders' verbal commitment and continuous involvement and action that lead to organisational.

The initial step of the process is for a group of interdisciplinary team members to carefully review the organisation's just culture framework and accountability practices, and they should consider fair and equitable responses to errors/near misses. For instance, technically proven tools such as a Just Culture Algorithm can serve as a basis for distinguishing between human errors, unintentional violations, and reckless, deliberate violations, which need a wide range of different interactive methods, viz. educational materials, new safeguards, and administrative punishments (Boysen, 2013). Such goals for approach planning and choice criteria definition would be proactive and not require harsh adverse event reactions.

As substantial as policies are, there will be a need for custom-designed training programs that will be taught to all staff about the concepts of just culture, psychosocial security, and accountability toward the creation of a learning environment (Frankel et al., 2006). Focus must be placed on training organisational leaders, managers, and supervisors to embrace principles and model accountability skills like: Focus must be placed on training organisational leaders, managers, and supervisors to embrace these principles and model accountability skills like:

Recognising mistakes by applying rectification based on discipline matters as fact-finding and cyclical education instead of punishment.

Reinforcing the idea that whatever talk is heard from front-line staff is welcomed if they do not take the plunge into place bashing.

Sitting at a council meeting is not an affliction. Still, it becomes successful when the body of council members responds to staff reports and input with genuine curiosity rather than defensive statements.

In a situation where people are fallible and don't feel psychologically careful while questioning the decisions, a new habitat should be developed.

Analyzing occurrences of these events or such near-miss ones as opportunities to enhance the potential for process improvement.

This leadership training could be added to available employee onboarding processes and combined with formalised feedback and performance management solutions. To summarise, appreciating a just culture should form important leadership expertise, be accurately translated into the evaluation system, and be closely related to increases, achievements, and accountability data.

The next step is to implant a successful systematic set of procedures that sustain these ethical principles and social learning. Such a system should be proactively audited to track for repetitive system faults and events happening very close to the one of disaster; moreover, specific procedures for Root Cause Analysis and stronger process controls should be implemented. In addition, the procedure must involve weekly re-analysing of the safety data, employee survey outcomes, accountability action whenever a persistent deficiency is observed, and steps to improve notices at not meeting.

The organisation will not be optimistic, but real, sustainable improvement will depend on leadership support and simple but tight commitment tracked over the years. At this depth of holistic cultural transformation, a mission with the highest priority designed to be broadly crosscutting will promise better results. It can't be accomplished with timeless short-term initiatives or unclear goals.

The Board of Directors should start by developing a safety policy embedded in the organisation's symbolic words and actions, from the senior executive ranks down to the clinical leadership, to be a beacon of safety. To connect with people and make it crystal clear how the mission and values impact the entire organisation, leaders should embrace the principles daily, talk about principles in short stories, highlight praise to the personnel who follow the principles, and maintain records of those who don't.

A top priority will be creating consistent communication and providing sufficient information around safety expectations, objectives, key performance indicators, and progress reports. This might involve regular leadership safety briefings, visual reporting on posters in every work area, reviewing case studies from staff meeting errors, and maybe public accountability scorecards that would be sent to the community.

The recent patient safety culture survey findings reveal the kind of focus that should be given to small details that may be always and often overlooked. The three main problem components - incidents of variable reporting, limited teamwork across the units, and the adverse perceptions of the top leadership towards concerns: are all the leading causes that this organisation should battle against.

On the other hand, what is pixelated would not be a shortcoming; rather, it is like a lighted path on which countries' improvement path should be found. The realisation of multidimensional results in these mandates will be a formidable challenge, and substantial resource deployment, in addition to sustainability, is of paramount importance. But this is something this organisation must deliberately undertake if its desire to edge up high reliability is not to be mere words.

Implementing the key step-by-step hierarchy on reporting systems, transferring process, just culture, and leadership in safety will bring about cultural reforms, which will result in time-frame risk resiliency. Success will be determined by energised involvement not just of authorities at the top but also through the organisation for true conversion of safety to a vivid institutional value.

The survey findings imply a revitalisation that goes to the root, once and for all - embedding key practices and thought patterns into the central nervous system of work through a strong reinforcement of a new generation of expectations, proper accountability for performance, and a firm commitment to hazard ill and disasters prevention as the strategic mission.

Along the journey ahead, there will be many challenges, but not even the riskiest of paths will be worse than inaction. The respondents in this survey would be a gold mine by allowing us to strengthen the organisation's safety and security culture from the foundation before a terrible security breach. By wholeheartedly accepting that the data is directionally correct and with the sense of purpose to act thereon, we can ensure that every patient interaction is with greater confidence and the hospital operations more reliably ensure optimal patient safety and satisfaction.

REFERENCES

Boysen, P. G. (2013). Just culture: A foundation for balanced accountability and patient safety. Ochsner Journal, 13(3), 400406.

Flinchbaugh, K. D., Cheng, P., Thawley, R., Sepucha, K., & Lee, J. Y. (2021). Quality of handoffs for pediatric inpatients: A mixed methods study of the experiences of pediatric residents and staff. BMC Health Services Research, 21(1), 1153. https://doi.org/10.1186/s12913-021-07068-

Frankel, A. S., Leonard, M. W., & Denham, C. R. (2006). Fair and just culture, team behaviour, and leadership engagement: The tools to achieve high reliability. Health Services Research, 41(4 Pt 2), 16901709. https://doi.org/10.1111/j.1475-6773.2006.00572.xReason, J. (1997). Managing the risks of organisational accidents. Routledge.

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768770. https://doi.org/10.1136/bmj.320.7237.768The Joint Commission. (2017). Inadequate handoff communication. Sentinel Event Alert, (58), 16. https://www.jointcommission.org/-/media/discontinued-unorganized/imported-assets/tjc/system-folders/assetssystem%20redesign/2019%20tracer%20materials/sea_58_hand_off_comms_9_6_17.pdfWeick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). Jossey-Bass.

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