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Exercise 5.2 Objective: To apply equitable results for individuals…

Exercise 5.2 Objective: To apply equitable results for individuals involved in an adverse event. Instructions: Read the following four case studies. Determine the appropriate results for the individual who made the mistake. Case 1: Transport Staff Member Mistakenly Tries to Restrain Patient A patient transport staff member is passing the psychiatric unit and notices a nurse struggling with a confused and argumentative patient who was trying to leave the unit. The transporter tries to restrain the patient, but he seizes the patient roughly and fractures several of the patient’s ribs. The transporter real-ized he had breached procedures as the nurse had not asked for assistance and nobody appeared to be in immediate physical danger; he also had no training in handling combative patients. He admits to his supervisor that he had simply decided to “pitch in” and help.

 

Case 2: Housekeeper Mistakenly Overlooks Posting a Wet-Floor Sign A housekeeper is waxing the floors near the hospital cafeteria at 1 a.m. He cannot find a wet-floor sign and would have had to go back to the office to find one. He believes there will not be any foot traffic in the area at this time of night, so he does not go to the trouble of finding a sign. He leaves to take his mid-shift break while the floor dries. A young patient who could not sleep walks with his mother near the vending machine and slips on the wet floor, breaking his wrist. The housekeeping staff often have to search for wet-floor signs, which causes them to get behind in their work. Although the manager is aware of this problem, no additional signs have yet to be purchased.

 

Case 3: Nurse Mistakenly Omits Double-Check A nurse is getting ready to administer a high dose of insulin. Consistent with hospital policy, she looks for another nurse to review her calculation and the amount in the syringe vial, prior to administration. She is unable to find another nurse and fails to perform the double-check step. The patient receives an over-dose of insulin, which results in complications requiring transfer to the ICU.

 

Case 4: Therapist Mistakenly Ignores Alarm Bell A confused patient in a geriatric care unit wanders down the hall and goes out the fire door. The alarm bell sounds but the physical therapist walking down the hall just ignores it, thinking that it’s just another false alarm. The patient is later found outside lying on the ground after falling and breaking a hip.

 

 

Chapter 5 of your textbook discusses organizational culture,…
Chapter 5 of your textbook discusses organizational culture, calling it the ‘soil,’ in which the ‘seeds’ (management techniques) can prosper (p. 80). For this week’s discussion, you are encouraged to take 2 of the 4 scenarios presented in Exercise 5.2 (p. 80) and evaluate them for potential clues to the organizational culture they occur in.

 

For your two scenarios, discuss the following: What do you hypothesize are some of the cultural characteristics the scenario occurred in and why? What are the appropriate results for the individual who made the mistake? If you managed the department the mistake occurred in, what lessons does this scenario offer you, and what actions do you either learn more about or correct the issues?

 

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