Important determinants to whether or not an adverse medical event has occurred

When adverse medical events occur, there can be many determinants as to their happening.  Factors such as protocol compliance, staffing and safety levels and even patient perception can play a role in the uncovering of, or contribution to, an adverse medical event.  However, if an unfavorable event should occur, some such determinants may be considered more important than others. 

It is one’s opinion that the factor of patient perception is important when determining if an unfortunate medical event has happened; however it is not the most important.  On one hand, the patient’s intuition may tell them that something is wrong, for instance, internally.  In a major mishap, perhaps a surgical instrument was left in the patient.  In a situation like this, the patient perception can play a huge role in the determination of error.  However, on the other hand, some patients may have a cognitive illness and therefore not be a legitimate source of perception.  Thus, one feels that when using patient perspective as a motivator, for examining a possible adverse event, it should be approached on a case-by-case basis.

One factor that can be deemed as more important than patient perception is protocol compliance.  Following protocol, for example, in a surgery, is important each and every single time a surgery is performed.  If a protocol checklist is not completed after a procedure, situations such as instruments being left in patients can occur.  The checklist can be a huge indicator of something having adversely occurred.

Another determinant that may be considered more important than patient perception is the level of safety that is enacted within an organization.  Clearly if safety is not at optimal levels, accidents can occur.  For example, if bed linens or physician robes are not cleaned daily, they can be breeding grounds for infectious bacteria.  Implementing a checklist and keeping track of it can be a very important determinant as to whether all safety measures are being used when re-using materials.

A last, but certainly not least, example of an important determinant as to whether or not an adverse medical event has occurred is the level of staff that is present during such an event.  To exemplify, ensuring that the proper amount of nurses are always available in the intensive care unit and controlling for their presence can prevent a disastrous event from taking place.  If such an event should occur, having controls will give an insight into where a mistake has taken place.

Overall, there are many, many determinants that can be reliable indicators as to whether or not an unfavorable event has occurred.  Patient perception is one of those, however there are others that can be considered more important.  Listening to patients and respecting their thoughts is always good practice; yet taking their overall situation into consideration, when entertaining a move toward investigation of an adverse event, is even better practice.

Elements to patient safety

As an administrator of healthcare, ensuring quality is one of the most important tasks that we accept to fulfill.  Along with quality, it is important to maintain an exceptional standard of patient safety.  I think that most of us would agree that patient safety is an element of quality that portrays the standard to which your organization performs; and this particular element can only be successful with a committed management staff.  According to Matthew Lambert, MD, senior vice president of the healthcare consulting firm Kaufman Hall, to be able to conserve the patient safety element in healthcare, there are six steps that must be accepted by all who work within the organization (Oh, 2012).

The first element pertains to management, as it is suggested that the patient safety culture begins with those who are in the leadership role (Oh, 2012).  This is where the phrase, actions speak louder than words, is applicable.  As a manager, it is necessary for your staff, patients and other leaders to see that you live by the program you implement for there to be full trust in the system.

Secondly, it is suggested that, as an administrator, you must be able to visualize what patient safety is for your organization and get your organization to that vision, if you are not already (Oh, 2012).  Performing a gap analysis will help management to see where your company stands in terms of where you are and where you want to be (Oh, 2012).  Presenting this analysis to staff is a visual way for all to understand how to get to a superior level of safety.

The third suggested step is that everyone within your organization, at every level, must be in appreciation and compliance with your concept of patient safety (Oh, 2012).  For your strategy to be successful it is crucial that every level of your staff is comfortable with your strategy, they understand it fully and they appreciate what your goals are.  Employees who are not comfortable with implementing certain protocols will lead to a breakdown of your vision and can ultimately lead to its failure.  Having open doors of communication with all levels of employees will help to secure their ability to implement your plan.

The forth step suggested is that the organization continually changes with the demands to which patient safety is needed (Oh, 2012).  Yes, you may have visualized where you are going with your plan for patient safety, but if part of your strategy is not meeting your safety requirements, it will need to be adjusted.  For instance, if employees do not seem to be regularly following safety protocols, maybe a method of monitoring employee actions could be put in place.

Next, it can be interpreted from Dr. Lambert, that the fifth part of ensuring patient safety culture is to provide a standard level of commitment to it, for all who are involved in an organization’s vision (Oh, 2012).  For example, this implies that a manager cannot let one mishap slide and another occurrence be punished; nor can a they decide to use fewer antibacterial soap stations in one wing of their hospital because that wing it not as heavily utilized.  Cutting corners doesn’t fulfill your commitment to patient safety and your employees can be misled in the implementation of your strategy that way.

Last, but not least, of importance is implementing a patient safety program that surpasses the need for management to enforce it (Oh, 2012).  Having a strategy that thrives on its own is the marker for its success.  For example, when the manager who everyone fears is not in the building and your patient safety vision is still at its highest level of performance, that is an indication that all members of the organization are on board and are committed to the safety of all.

Obviously these six steps are not the only means to ensure the safety of patients, staff and management, but it has proven to be effective by Dr. Lambert; as well as by representatives of The Joint Commission’s Center for Transforming Healthcare.  It is my hope that this is viewed as a simple outline for what can be a complex road to the fulfillment of exemplary safety measures.

Reference:

Oh, J. (June 4, 2012). 6 Elements of a true patient safety culture. Retrieved June 4, 2012 from Becker’s Hospital Review.  Website:  http://www.beckershospitalreview.com/quality/6-elements-of-a-true-patient-safety-culture.html