Boulton in risks. The Health and Safety Executive (HSE

 

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 in
every day in our life. The Department of Health (2006) stated that risks could
be reduced by as much as 50%if there is a record and analysed lessons from
previous risk incidents were. This would help to reduce the chances of
recurring mistake. Tingle (2006) also supported the above claim that it would
help 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 has
also been successfully put into practice. The first step is to identify the
risk, recognize strengths and weakness to reduce risk and reach the aim using a
method, 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 should
critically approximate past events as a goal to lessen risk in the healthcare
setting.

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The Health and Safety Executive
(HSE) (2006) identify five easy steps to assess risk in any work place
environment such as thefollowing; first step is to use risk check list method
to identify the risk, recognize strengths and weakness to reduce risk.The second
step using suitable risk management tools, such as a scoring system to assess
who 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 by
removing it if possible otherwise the hazard should be controlled by reducing
the chance of harm.

According to Waterhouse (2007) regards
record keeping, the fourth step of HSE risk management as the most important
part and this allow keeping a record of the patient’s risk assessment which can
be shared amongst colleagues as critical practice to protect patients from
harm. The NMC code of conduct (2008) also support the sharing of information
among colleagues as good practice to maintain the safety of the patients. The daily
review and ongoing basis to protect patients from hazards as the last step of
risk assessment. This will enable monitoring to determine the progress and
changes to their condition. Therefore it is vital that they must always be
accurately recorded and kept up to date. Fullbrook (2007) agreed with these
studies, adding that from the nurse’s point of view, assessment is the most
important part of risk management. Nurses often are the first to identify
potential difficulties in their working environment, as they are there on a
daily basis.

(ii)The organization
consists of the staff; the behavior of the individual members will impact on
the outcomes of the organisation. it is necessary to explore the way the
culture influences the behavior of the nursing staff, and in turn how the
behavior of the staff influences the organizational outcome.This
report will explore the influence of organisational culture on risk as identified in the scenario
of the student nurse. Therefore, nurses and
managers are advised to create a culture that will encourage reporting of error
to reduces the possibility of error and increase the level of patient safety in
their organizations. Harvard Professor Dr. Lucian Leape said people are
punished for making mistake which is the single greatest impediment to error
prevention in the medical industry. This lead to culture of shame and blame where people shy away when they foresee harm to avoid
been blamed (Gov.uk, 2018). The GMC and NMC
guidance state clearly that the professional tribunal should give credit to doctors,
nurses or midwives who admit wrong and apologise (Gov.uk,
2018)

Organizational culture as
described by Robbins and Coulter (2012) is the shared values, beliefs, or
perceptions held by employees within an organization. For that reason, organizational
culture reflects the values, beliefs and behavioral norms that provide guardian
to employees in all situation that the staffencounter.Therefore, organization
culture can influence the attitudes and behavior of the staff (Scott-Findlay
and Estabrooks, 2006). The Understanding of organization’s core values can stop
possible internal conflict (Watson et al., 2005).Culture is socially imbibed
and convey by members, this provides the rules that guides the behavior within the
organizations(Yang, 2007).

To have a successful hospital outcome, adequate organisational
culture approaches must in place such as reporting identified key safety
indicators, updating, and posting results on a timely manner, using root-cause
analyses to investigate medical errors and near misses (Apold, Daniels, &
Sonneborn, 2006; Connor, Ponte, & Conway, 2002).

The
role of leadership in organisation risk or patient safety is essential element
to design, promote and develop a culture of safety. Blake et al. (2006) concluded that
identified administrative leadership as the most significant architects for
creating and encouraging a culture of safety. Likewise,Dickey (2005) declared in
an editorial on “Creating a Culture of Safety,” that a culture of safety must
start from the top with the chief executive officer (CEO) to the bottom level
of the healthcare system. For example, in the scenario, the team leader did
not demonstrate a transformational style of leadership which need to give
support to the student nurse. The organisation failed to identify the level of
competence required to securely manage the airway of a patient with a
tracheostomy. The student nurse did not alert a more senior member of the
nursing staff, Charge Nurse Waring, about the problem because Nurse Waring was
busy and she was unsure whether her assessment that the airway was blocked was
correct.This demonstrated lack of communication.

Hand-off communication is a method to assure information is
transferred as a cohesive plan between shifts, departments, and units (Blake et
al, 2006). Frankel et al. (2003) suggest implement forms of communication such
as briefings. The procedure of briefing did not reflect in the scenario.

 

(iii)Leyshon (2005) suggested identifying of risk before
any action to manage it. This section will identify a process that can
identify risks. There are several tools that can be used to identify risk in a
work place such as; Swiss Cheese Method (Reason 1997), Shell model human
factors (Hawkins, 1989), Root Cause Analysis (Wilson et al, 1993). The SHELL Model emphasized onthe relationship of human factors and the
aviation environment(Reinhart,1996) while Hawkins, (1989) states that It
is generally known that most of the air accidents are related to human errors,
while the mechanical failures in aircraft maintenance today has enormously been
on the decrease with many new high technological equipment inventions.

? This report will consider
Root cause analysis (RCA) as to others because RCA is a method of resolving
problemby identifying the root causes of faults or
problems (Wilson et al, 1993).According
to Institute for Healthcare Improvement (IHI), Root cause analysis (RCA) is a
process 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 15
years, success has been variable both within and across institutions.

The (International Air
Transport Association, 2016) claimed that the RCA is based on four general
principles which define and describe properly event or problem built on five
whys technique. 5 Whys is a repeated inquiring procedure used to discover the
cause and effect of anevent.It is practice of asking question five times why
event 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 an
RCA such as define the problem, understanding the problem, immediate action,
corrective action and confirm the solution. Vorley (2008) additionally identified
the limitation of 5 whys technique as a tool that does not consider all
possible failure of causes and unable to identifying all root causes of a
problem.

Based on the scenario, there
are several risk factors that can be identified such as; The student nurse was struggling to cope with workload
during training and all tasks are new that needed more mental effort to
complete.

There was evidence of powerhierarchy in the scenario, Charge Nurse
Waring seems unapproachable to junior staff, making it less likely that the
junior will flag up a problem or seek advice. Charge Nurse Waring should
reflect on their own leadership style and how they allocate student nurses or
junior nursing staff to patients.

The
student nurse was still in training, she was new to the ward and did not have
time to get to know staff or patients, no assessment of risk or procedures
associated with managing tracheostomies and no team support.

 Additionally, Organisation and management risk
such as the student nurse should have been supervised and not left in charge of
a high-risk patient with a tracheostomy. There should have been warnings or
instructions near the patient to indicate required action if occlusions
occurred, 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 and
maintaining safe systems of care, designed to reduce adverse events and improve
human performance (Reason, 2000).

The
use of incident monitoring mechanisms is a method of mitigating risk which will
help to identify, process, analyse and report incidents or near misses with the
opinion to prevent their recurrence in the future (Barach and Small, 2000).

Complain
can be used to identified in improving health care. Though complain is an expression
of dissatisfaction from patient or family member with their health care. It can
be an opportunity for improving clinical practice. For example, Complaint often
highlight problem that require an attention (Walton 2001).

However,
the Institute of Medicine (IOM), claimed there is need to look beyond human
error to mitigate risk in health care in a report released in 1999 titled To
Err is Human: Building a Safer Health System (Kohn et al, 1999).

The
IOM claimed that patient safety requires dramatic and systemwide changes such
as recognizing and applying actions to prevent error has the highest potential
effect. Therefore, the IOM described a plan to create a safer health care
system and a systematic way to patient safety. The plan of the IOM
recommendations described as follows:

The
IOM recommend the creation of a National Center for Patient Safety to ensuring
basic safety, establishing national safety goals, tracking progress in meeting
them, and investing in research to learn more about preventing mistakes as well
as a clearinghouse and source of effective practices that would be shared
broadly.

The
IOM recommendation establish a nationwide and mandatory public reporting systemto
encourage the growth of voluntary and confidential reporting systems.The
practitioners and health care organizations can learn and correct problems
before serious harm occurs.Though, the information would be made confidential
and protected by the Federal legislation e.g., medical mistakes that have no
serious significances.

The
IOM advised health care organizations to produce an environment in which safety
is a top priority, for example, the leaderships need to inculcate the principle
and accountability for patient safety as their priority. This can be done by designing
jobs and working conditions for safety; standardizing and simplifying
equipment, supplies and processes; and avoiding reliance on memory.

The IOM further claimed that
organisations need to understand the sources of error and pairing them with
effective ways to reduce them known as user-Centered Design. This is to make
things observablewhere user can determine what actions are possible at any
moment, 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 provision
of checklists and demanding their use at regular intervals, limiting long
shifts (can reduce workload) and rotating staff can likely help to reduce error
at workplace.When developed, updated and used wisely, protocols and checklists
can enhance safety.

Nurses have a duty of care to patients.
It is prudent that all the effort to mitigate risk are followed to avoid
litigation. Generally, the law imposes a duty of care on a health care
practitioner in situations where it is “reasonably foreseeable” that
the practitioner might cause harm to patients through their actions or
omissions (RCN,2018)

While the duty of candour state that every
healthcare professional must be open and honest with patients when
something that goes wrong with their treatment or care causes, or has
the potential to cause, harm or distress (NMC, 2017)