Patient Safety Culture
Analysis
The patient survey results at Mesa Valley hospital, where Ms. Viani was hospitalized, had shown some flaws that were to be addressed by the management before the situation worsened. The weaknesses within the facility were identified to be in staffing, which recorded a low percentage of 25%. This situation is related to increased rates of medical errors due to increased missed nursing care and lack of engagement among healthcare practitioners. The situation can be poor due to understaffing, which may increase the rate of mortality, high risk of infection and increased number of falls. Additionally, the survey revealed that there was a low safety culture and non-punitive environment that was rated at 20% because these areas are usually critical there are to be considered great for improvement. Lastly, as per the survey, even though teamwork had a greater score of 80% and organizational learning and continuous improvement a score of 78%, the remaining percentage played a significant role in the medical error.
Outcome
According to the survey, the cause of Ms. Viani’s Lasix overdoes and falling was due to poor staffing response and a non-punitive environment. Even though the hospital had a high score of 78% which indicated that there was continuous improvement and organizational learning, poor staffing response could still lead to error. Additionally, the 80% positive score rate on teamwork among the healthcare personnel indicated that there was still 20% room for such an error to occur. Poor staffing response still contributed greatly to the condition that Ms. Viani experienced. Limiting the rate of punitive and improving safety culture would have been a great step to limiting the error caused by a lack of professional skills.
Recommendation
The situation that occurred at Mesa Valley hospital can be prevented from reoccurring by ensuring that the hospital health care personnel are competent, qualified and capable of performing their tasks appropriately. This could be a great way to ensure that there is always coordination among healthcare workers taking care of a given patient. Competent healthcare workers will be able to recognize the appropriate time to issue or prescribe medicine to a patient. Proper time management would have prevented the errors in time overlaps of administering Lasix 20 mg IV to Ms. Viani. A competent nurse should involve the patient in the treatment process to be aware of the patient’s conditions as well as health information. Professional and competent healthcare personnel should ensure that there is a regular check on the patients and a proper report on the information concerning the patient. Lastly, the hospital should guarantee that the team responsible for emergency services is always alert to avoid severe injuries related to falls and as well mortality rates.
Communication
Strategy
The medical error of overdoing Lasix 20 mg IV that triggered light-headedness, falling and loss of consciousness was caused by poor time management, lack of communication among the three health personnel and poor response by the rapid response team. There are several ways in which the error could have been prevented or can be prevented from reoccurring; one of the ways is the Team-based care model, for instance, communication TeamSTEPP. This model is used to address the healthcare needs of the patients in a coordinated manner among healthcare workers. When embraced by medical personnel, physicians, administrators, patients and support staff, it improves efficiency, reduces workload and cost, and improves provider and patient satisfaction (Lyon et al., 2018). Additionally, communication TeamSTEPPS is a productive part of the model that should be considered. This method will improve communication and collaboration among health, leading to quality care among healthcare workers.
Safer Patient Care
Team-based care is responsible for a positive patient experience and as well meeting the goals of value-based care. This model is productive because it promotes team players among individuals’ medical personnel. These individuals are able to work together as a team to ensure that patients’ problems are solved. This model encourages intrateam communication, a proper way of building quality servicing to patients. The team-based care model ensures that medical practitioners share values and principles such as humility and honesty. Relying on this model, especially in communication, TeamSTEPP would have served a greater role in the prevention of Ms. Viani’s error. The three medical personnel, the nurse, the laboratory technologists and the hospitalists, would have coordinated the patient’s treatment process and no overdose situation would have occurred.
Measurement
The command team effectiveness (CTEF) and the Donabedian Model are effective in ensuring measuring the effectiveness of Team-based care. The two models were considered effective through the utilization of the 4 psychometric properties, which include structural integrity, internal consistency, content validity, and interrater agreement (Kash et al., 2018). Donabedian Model is a three-component approach that provides a framework for analyzing whether there is quality care within given hospital care. Its components, such as process, structure and outcomes, are applied to check on the progress of the individuals who have adopted the Team-based care model. Command team effectiveness measures various outcomes that are based on team and task outcomes.
References
Kash, B. A., Cheon, O., Halzack, N. M., & Miller, T. R. (2018). Measuring Team Effectiveness in the Health Care Setting: An Inventory of Survey Tools. Health services insights, 11, 1178632918796230.
Lyon, C., English, A. F., & Smith, P. C. (2018). A team-based care model that improves job satisfaction.Family practice management, 25(2), 6-11.