Boulton et al. (2000)claimed that it is not possible to create a business that doesn’t engage in risks.The Health and Safety Executive (HSE 2006) claimed that risks exist inevery day in our life. The Department of Health (2006) stated that risks couldbe reduced by as much as 50%if there is a record and analysed lessons fromprevious risk incidents were.
This would help to reduce the chances ofrecurring mistake. Tingle (2006) also supported the above claim that it wouldhelp to save the NHS costs if lessons were learned from previous incidents. The Health and Safety Executive (HSE) (2006)identify five easy steps to assess risk in any work place environment which hasalso been successfully put into practice. The first step is to identify therisk, recognize strengths and weakness to reduce risk and reach the aim using amethod, such as a risk check list. Therefore,risk need to be managed throughout health care organisations. Leyshon(2005) suggested that the nurses and other healthcare professionals shouldcritically approximate past events as a goal to lessen risk in the healthcaresetting.The Health and Safety Executive(HSE) (2006) identify five easy steps to assess risk in any work placeenvironment such as thefollowing; first step is to use risk check list methodto identify the risk, recognize strengths and weakness to reduce risk.
The secondstep using suitable risk management tools, such as a scoring system to assesswho may be harmed and how. The third step is to evaluate the risk. According to Young and Woodock (2011) adduced that to eliminate the hazard byremoving it if possible otherwise the hazard should be controlled by reducingthe chance of harm.
According to Waterhouse (2007) regardsrecord keeping, the fourth step of HSE risk management as the most importantpart and this allow keeping a record of the patient’s risk assessment which canbe shared amongst colleagues as critical practice to protect patients fromharm. The NMC code of conduct (2008) also support the sharing of informationamong colleagues as good practice to maintain the safety of the patients. The dailyreview and ongoing basis to protect patients from hazards as the last step ofrisk assessment. This will enable monitoring to determine the progress andchanges to their condition. Therefore it is vital that they must always beaccurately recorded and kept up to date. Fullbrook (2007) agreed with thesestudies, adding that from the nurse’s point of view, assessment is the mostimportant part of risk management. Nurses often are the first to identifypotential difficulties in their working environment, as they are there on adaily basis.(ii)The organizationconsists of the staff; the behavior of the individual members will impact onthe outcomes of the organisation.
it is necessary to explore the way theculture influences the behavior of the nursing staff, and in turn how thebehavior of the staff influences the organizational outcome.Thisreport will explore the influence of organisational culture on risk as identified in the scenarioof the student nurse. Therefore, nurses andmanagers are advised to create a culture that will encourage reporting of errorto reduces the possibility of error and increase the level of patient safety intheir organizations. Harvard Professor Dr.
Lucian Leape said people arepunished for making mistake which is the single greatest impediment to errorprevention in the medical industry. This lead to culture of shame and blame where people shy away when they foresee harm to avoidbeen blamed (Gov.uk, 2018).
The GMC and NMCguidance state clearly that the professional tribunal should give credit to doctors,nurses or midwives who admit wrong and apologise (Gov.uk,2018)Organizational culture asdescribed by Robbins and Coulter (2012) is the shared values, beliefs, orperceptions held by employees within an organization. For that reason, organizationalculture reflects the values, beliefs and behavioral norms that provide guardianto employees in all situation that the staffencounter.
Therefore, organizationculture can influence the attitudes and behavior of the staff (Scott-Findlayand Estabrooks, 2006). The Understanding of organization’s core values can stoppossible internal conflict (Watson et al., 2005).Culture is socially imbibedand convey by members, this provides the rules that guides the behavior within theorganizations(Yang, 2007).To have a successful hospital outcome, adequate organisationalculture approaches must in place such as reporting identified key safetyindicators, updating, and posting results on a timely manner, using root-causeanalyses to investigate medical errors and near misses (Apold, Daniels, &Sonneborn, 2006; Connor, Ponte, & Conway, 2002).
Therole of leadership in organisation risk or patient safety is essential elementto design, promote and develop a culture of safety. Blake et al. (2006) concluded thatidentified administrative leadership as the most significant architects forcreating and encouraging a culture of safety. Likewise,Dickey (2005) declared inan editorial on “Creating a Culture of Safety,” that a culture of safety muststart from the top with the chief executive officer (CEO) to the bottom levelof the healthcare system. For example, in the scenario, the team leader didnot demonstrate a transformational style of leadership which need to givesupport to the student nurse. The organisation failed to identify the level ofcompetence required to securely manage the airway of a patient with atracheostomy.
The student nurse did not alert a more senior member of thenursing staff, Charge Nurse Waring, about the problem because Nurse Waring wasbusy and she was unsure whether her assessment that the airway was blocked wascorrect.This demonstrated lack of communication.Hand-off communication is a method to assure information istransferred as a cohesive plan between shifts, departments, and units (Blake etal, 2006). Frankel et al. (2003) suggest implement forms of communication suchas briefings.
The procedure of briefing did not reflect in the scenario. (iii)Leyshon (2005) suggested identifying of risk beforeany action to manage it. This section will identify a process that canidentify risks. There are several tools that can be used to identify risk in awork place such as; Swiss Cheese Method (Reason 1997), Shell model humanfactors (Hawkins, 1989), Root Cause Analysis (Wilson et al, 1993). The SHELL Model emphasized onthe relationship of human factors and theaviation environment(Reinhart,1996) while Hawkins, (1989) states that Itis generally known that most of the air accidents are related to human errors,while the mechanical failures in aircraft maintenance today has enormously beenon the decrease with many new high technological equipment inventions.? This report will considerRoot cause analysis (RCA) as to others because RCA is a method of resolvingproblemby identifying the root causes of faults orproblems (Wilson et al, 1993).
Accordingto Institute for Healthcare Improvement (IHI), Root cause analysis (RCA) is aprocess widely used by health professionals to learn how and why errors occur.While RCA has been part of health care and patient safety for more than 15years, success has been variable both within and across institutions.The (International AirTransport Association, 2016) claimed that the RCA is based on four generalprinciples which define and describe properly event or problem built on fivewhys technique. 5 Whys is a repeated inquiring procedure used to discover thecause and effect of anevent.It is practice of asking question five times whyevent occurred to get to the root causes of the failure.Vorley (2008) revealed that,once the problem has been identified, there are five basic steps to complete anRCA such as define the problem, understanding the problem, immediate action,corrective action and confirm the solution.
Vorley (2008) additionally identifiedthe limitation of 5 whys technique as a tool that does not consider allpossible failure of causes and unable to identifying all root causes of aproblem.Based on the scenario, thereare several risk factors that can be identified such as; The student nurse was struggling to cope with workloadduring training and all tasks are new that needed more mental effort tocomplete.There was evidence of powerhierarchy in the scenario, Charge NurseWaring seems unapproachable to junior staff, making it less likely that thejunior will flag up a problem or seek advice. Charge Nurse Waring shouldreflect on their own leadership style and how they allocate student nurses orjunior nursing staff to patients.Thestudent nurse was still in training, she was new to the ward and did not havetime to get to know staff or patients, no assessment of risk or proceduresassociated with managing tracheostomies and no team support. Additionally, Organisation and management risksuch as the student nurse should have been supervised and not left in charge ofa high-risk patient with a tracheostomy. There should have been warnings orinstructions near the patient to indicate required action if occlusionsoccurred, this be necessary, as untrained staff was delivering care. Therefore,organisations need to have in place a standard procedure to mitigate risk.
(iv).The success of a riskmanagement programme, however, depends on the creating andmaintaining safe systems of care, designed to reduce adverse events and improvehuman performance (Reason, 2000). Theuse of incident monitoring mechanisms is a method of mitigating risk which willhelp to identify, process, analyse and report incidents or near misses with theopinion to prevent their recurrence in the future (Barach and Small, 2000).
Complaincan be used to identified in improving health care. Though complain is an expressionof dissatisfaction from patient or family member with their health care. It canbe an opportunity for improving clinical practice. For example, Complaint oftenhighlight problem that require an attention (Walton 2001).However,the Institute of Medicine (IOM), claimed there is need to look beyond humanerror to mitigate risk in health care in a report released in 1999 titled ToErr is Human: Building a Safer Health System (Kohn et al, 1999).TheIOM claimed that patient safety requires dramatic and systemwide changes suchas recognizing and applying actions to prevent error has the highest potentialeffect. Therefore, the IOM described a plan to create a safer health caresystem and a systematic way to patient safety. The plan of the IOMrecommendations described as follows:TheIOM recommend the creation of a National Center for Patient Safety to ensuringbasic safety, establishing national safety goals, tracking progress in meetingthem, and investing in research to learn more about preventing mistakes as wellas a clearinghouse and source of effective practices that would be sharedbroadly.
TheIOM recommendation establish a nationwide and mandatory public reporting systemtoencourage the growth of voluntary and confidential reporting systems.Thepractitioners and health care organizations can learn and correct problemsbefore serious harm occurs.Though, the information would be made confidentialand protected by the Federal legislation e.
g., medical mistakes that have noserious significances.TheIOM advised health care organizations to produce an environment in which safetyis a top priority, for example, the leaderships need to inculcate the principleand accountability for patient safety as their priority. This can be done by designingjobs and working conditions for safety; standardizing and simplifyingequipment, supplies and processes; and avoiding reliance on memory.The IOM further claimed thatorganisations need to understand the sources of error and pairing them witheffective ways to reduce them known as user-Centered Design.
This is to makethings observablewhere user can determine what actions are possible at anymoment, for example how to return to an earlier step, how to change settings,and what is likely to happen if missed a step in a process. Furthermore, the provisionof checklists and demanding their use at regular intervals, limiting longshifts (can reduce workload) and rotating staff can likely help to reduce errorat workplace.When developed, updated and used wisely, protocols and checklistscan enhance safety.Nurses have a duty of care to patients.It is prudent that all the effort to mitigate risk are followed to avoidlitigation.
Generally, the law imposes a duty of care on a health carepractitioner in situations where it is “reasonably foreseeable” thatthe practitioner might cause harm to patients through their actions oromissions (RCN,2018)While the duty of candour state that everyhealthcare professional must be open and honest with patients whensomething that goes wrong with their treatment or care causes, or hasthe potential to cause, harm or distress (NMC, 2017)