Introduction
Patient safety and well-being are among the most important and critical considerations of healthcare professionals. To keep the population healthy and happy, doctors, nurses, managerial staff, and other types of people work in the medical industry. The process of providing patient care is complex and multi-faceted, requiring the cooperation of all of a hospital’s staff. However, this can be quite difficult when a particular part of the system is unable to interact with others due to willful ignorance. This case study will examine a few different cases of willful ignorance among health professionals, leading to the endangerment of patient safety and prosperity.
The Primary Causes for the Systemic Risk for Patient Safety
A number of cases where patient safety or wellbeing was compromised have been found during the course of the study in question. Most cases of risk discussed in the paper have been made in relation to willful blindness and inaction of hospital staff. An inability of BBH’s higher management and leadership to take decisive action in the face of incompetence has led to the creation of systematic risk for patients. Being presented with evidence in multiple instances, the executive branch of the hospital and senior officials did not listen to the concerns of the nurses or doctors. Another consideration for the hospital in question is the lack of proper care and support for patients after surgery, including a limited number of beds and ICU backup. Credentials, qualifications, or competencies of doctors from the hospital were not reevaluated, and the proper response to the concerns of outside parties was significantly delayed.
Examining the case of MHS, the patient safety concerns have been raised from a variety of sources, including the lack of response of the upper management, the general disregard for safety procedures, and a lessened concern for proper procedure. MHS management has chosen to continually reinforce the notion of no problems being present in the hospital facility.
Why These Risks Occurred and Resulted In Significant Patient Morbidity & Mortality
For BBH, the majority of risks were connected with malpractice and lack of professionalism from the acting director of surgery, Dr. Jayant Patel. However, there are a number of specific reasons why the risks associated with Patel’s practice were recognized and mended in such a delayed fashion and actively ignored. Firstly, the man’s qualifications were not sufficiently examined during the hiring process, allowing Patel to leave out information about his limit on surgical practice set by two foreign medical boards. The restrictions put on the man should have been taken into consideration and barred him from being offered a position of power and influence in the hospital. Furthermore, they should have acted as a signifier of Patel’s general incompetence as a surgeon. Following these initial mistakes, the mistakes of the director of surgery were willingly ignored, both by the executive staff at the hospital and other officials. Increased rates of post-surgery complications, increased patient mortality, and unaddressed infection risks were all swept under the rug for a prolonged period of time. The concerns of nurses, who have been consistently submitting complaints and evidence of the man’s incompetence, were further disregarded. As noted by the study, the opinions and thoughts of nurses on that matter were both treated as lesser and discredited by the director of medical service. The genuine, evidence-based, and consistent concerns were treated as cases of personal conflict, and the upper management took the side of Patel consistently. Furthermore, the array of reports provided by hospital staff was willingly misinterpreted as not being truthful or legitimate and seen as a way to undermine Patel’s professional image. This combination of factors has contributed to an increased danger to the patients, their wellbeing, and safety. Multiple people have suffered severe complications or passed away as a result of the surgeon’s inability to perform oesophagectomy and the lack of comprehensive post-surgery support. The lack of post-procedural care and resources must also be noted as one of the major factors contributing to patient morbidity and mortality. BBH is noted for its lack of specialized facilities and staff for giving specialized care with proper regulations dictating that the hospital should transport its post-surgery patients to another medical facility in the period of 24 to 48 hours. However, this consideration was not followed through in multiple instances, leading to the hospital staff being unable to adequately handle the post-surgical aftercare in many cases.
In the case of MHS, it is more difficult to put the blame on one specific person, as the entirety of the organization has suffered from improper safety measures and management. Standards of medical practice were not properly upheld, especially in regards to surgery preparation and general patient safety. The willful medical blindness and lack of consideration for patients have led to increased rates of mortality, as well as injury. The concerns raised by the medical staff, primarily by a number of “whistleblowers,” including nurses Quinn and Owen, were either not only continuously ignored but actively punished and discredited. The leadership of the hospital has used increased surveillance and disciplinary action as a way to discourage the nurses that came forward and fully ignored their work concerns. The hospital’s department of health, ministers, and executives have been in denial of the overwhelming disregard for proper procedure in the hospital. Furthermore, during a major professional conflict between the two whistleblowing nurses and an anesthetist over proper safety considerations, an inappropriate course of action was chosen by the General Manager of MHS. The nurses had proposed that the safety precautions taken before a 10-year-old’s operation were not sufficient to guarantee their safety and minimize possible complications: proper patient assessment was not complete, and the check on the safety of equipment was not conducted. This conflict, while appearing to have perfectly valid grounds to occur, was treated as a personal disagreement between the staff, with the nurses’ concerns being fully disregarded. The circumstantial evidence was ignored, and retaliatory action was instead taken against the nurses. The continued and prolonged inability of hospital management and the executive branch to take into consideration, properly address, or understand the concerns of their staff has compromised the safety and wellbeing of patients. In an effort to write the mistakes off as unimportant or inexistent, the hospital’s department of health has persisted in ignoring the much-needed change and recognizing the mistakes in their operation.
Similar Examples Occurring in the Current Work Environment
In my current work environment, I feel that an array of similar circumstances have been present during different times of my work practice. In some aspects, I feel similar to the BBH nurses, who were unable to enact change through their channels of influence, even after seeing a doctor endanger the life and wellbeing of a patient. It has come to my attention multiple times that some of the proper safety procedures, considerations, and precautions are not being taken, compromising patient safety. Many of the practices, including checking medical equipment or running patient examinations, are made to ensure that a patient will have the best possible health outcomes, making their consistency and quality extremely important. Unfortunately, willful blindness to proper procedure and well potential consequences of medical mistakes have been exhibited on a number of occasions. When cases of misconduct or negligence have been reported by my colleagues in the past, the lack of counteraction or measures in response to that information by the management has also been a big point of concern for me. While limited action has been taken in regard to the medical practices, most of it has not led to comprehensive investigations into the hospital’s internal conduct of sufficient regulatory measures. The response is largely personalized, short-term and ineffective in addressing the core problems of the organization. I feel that more care should be put into both proper ensuring procedure, finding an effective response to those that violate it, and to introducing systemic change into the management practices. With the health considerations of today only growing direr, medical facilities and professionals need to pay extra care to the quality of services they provide, as well as the quality of patient outcomes that results from their work.
On a similar note, I also have to state some of the other connected concerns I have about my organization’s work. Besides a number of violations of safety checks, procedures and standards, I feel that the communication between the medical staff and the regulatory body of the hospital is poor. While my co-workers have showcased a considerable concern over some of the problems encountered in daily practice, only a small portion of these considerations are actually being heard or taken seriously by the executive staff. There is a lack of communication, as well as recognition of the problems nurses and doctors, encounter in their day-to-day work, which leads to the slower introduction of the change and poorer management of resources. The lack of action from the leadership leads to some of the issues concerning patient safety being left unanswered or remedied with temporary patchwork solutions. Many of the problems concerning the hospital’s organization, operation, and performance could have been properly addressed much earlier if the systems of communication between parties had been better. A direct line of feedback between regular staff and executive staff is needed, as it is the only way to introduce comprehensive and effective new strategies.
Evidence-Based Solutions to Address These Risks That Are Occurring in the Practice Environment
A variety of studies have been made on some of the effective ways of combatting hospital incompetence and increased risks to patient safety, including management frameworks, novel solutions, better reporting, and the engagement of patients themselves in the process. Taking a comprehensive approach, a better clinical governance framework could be applied in practice as a way to promote more rapid development and growth (7). This method can be used to keep continually improving the standards of care and operation, but it also requires strong and effective leadership to succeed. A structural improvement of the hospital is needed first, one that addresses both the need for better management and better medical care for patients. Research notes that the dissatisfactory performance of doctors and nurses can often be linked with professional burnout and bad organizational culture (9). Both of these factors can be significantly decreased by improving the leadership and their interactions with the rest of the staff. Improvement of leadership and management can result in the growth and development of individuals working in the hospital, as well as the general improvement of the quality of care (1). In this process, communication and open dialogue between different parts of the staff is especially important. Combining practical expertise with technical and theoretical knowledge, different medical experts can be used to collectively enact lasting change. For such an effort, however, good communication between different parts of the hospital is important, which is often difficult to find or accomplish. A collaborative vision of patient care must be established to promote better standards at medical facilities and improve work efficiency (8). The process of enacting change, then, will have to involve developing a better system for reporting medical mistakes and other complaints that the staff may have. The process of medical reporting has to be made more accessible and more encouraged, as currently, a large percentage of the staff show concerns over reporting medical errors (12). Current research suggests that more attention should be devoted to making error-reporting systems incentivize change, not work as a method of punishment and administration (4). While results are still inconclusive, the use of such systems can be effective in giving medical facilities more flexibility and responsiveness to their surroundings. From the nurse and doctor’s side of the issue, the number of medical mistakes also has to be combatted with a variety of strategies and approaches. Researchers note that mistakes made in conjecture with other mistakes are the most common type of mistakes that are often under-discussed. The authors also relate that using Structured Root Cause Analysis (RCA) can be effective in combatting many types of medical errors (5). The better and more thorough utilization of informational technology, especially EMR, is said to be effective in reducing the number of medical errors and is currently widely utilized for that purpose (11). Furthermore, it can be noted that the use of clinical networks has been linked to better standards of quality care, as it reinforces better leadership and organizational culture (3). The use of patient and general feedback, as well as the submission of medical error reports, has also been noted as one of the available ways of improving patient safety, a method that directly engages the subjects of medical care themselves (2, 6, 10). Overall, more organizational and reporting changes would be needed to improve the patient safety and quality of care at my hospital, and only through collective and structured change can that be accomplished.
Conclusion
It can be said that the process of controlling and ensuring the proper quality of healthcare is difficult, requiring a large number of people to work on a cooperative task while acting in the best interest of the patients. In such a setting, people often strive to make their job easier, overlook the problems facing their organizations, and refuse a change in the workplace. Such attitude was found in a number of cases, with most of them bringing direct or indirect harm either to the staff or the patients. The usage, development, and spread of varied response measures, including the ones that target nurses, the management, and the reporting system, must be made a priority to ensure a successful and developing medical organization.
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