Question

At the large multi-specialty clinic in which you work, there have been two near misses and one medical error because various clinicians did not follow up on patient results. Different caregivers were involved each time. After the second near miss, the physician involved was asked to leave the clinic.

A nurse who realized that his colleagues weren't consistently following up on patient results reported the problem to the clinic leadership right away.

Which response would be most consistent with a culture of safety?

A. Transferring the nurse to another clinic
B. Placing the item on the agenda for the leadership meeting next year
C. Thanking the nurse and asking him to keep quiet about it
D. Investigating the problem and seeking systems solutions

Answer 1

The most safety-oriented response is to investigate the problem and seek systemic solutions. This approach contributes to a culture of safety that prioritizes addressing systemic issues over individual blame. Cooperation between different healthcare roles is crucial for maintaining patient safety.

Step-by-step explanation:

The response that would be most consistent with a culture of safety following the failure of clinicians to follow up on patient results would be D. Investigating the problem and seeking systems solutions. This action shows a commitment to addressing underlying system issues rather than reacting to individual errors punitively or superficially. In a culture of safety, it is recognized that errors are often due to complex system failures rather than individual negligence. Adopting a system-focused approach helps to identify the root causes and avoid future incidents through systemic improvements and protocols.

In terms of the scenarios presented, there seems to be a tension between the immediate, decisive action and the importance of working within the existing cultural norms of an organization. Noel took immediate action which, while potentially saving money and time, may have caused disruption and stress within the team. On the other hand, Tracy is focused on the long-term integration of Noel within the organization and the potential negative impacts of their disruption.

In healthcare settings, nurses and doctors can have different perspectives on their work due to their different roles and authority levels. Regardless, both should be committed to patient safety, and the use of checklists or other protocols to improve follow-up on patient results should be approached as a collaborative team effort, acknowledging the complexity of healthcare delivery.

The clinic's system for the long-term follow-up evaluation is clearly identified as a flaw that needs addressing to prevent future incidents similar to the unfortunate case of possible HIV transmission due to syringe misuse by a healthcare worker. Ensuring such systems are in place is vital for the safety and well-being of patients.