EXECUTIVE SUMMARY
After falling and experiencing chest discomfort, Makena, a Parkinson's patient, was admitted to a healthcare facility. Before being seen by a specialist in accident and emergency, she waited for more than three hours in an emergency. After receiving a bronchitis diagnosis, Makena was moved to a different hospital. She was trembling and growing more nervous as the days went by because she hadn't received her Parkinson's medicine. This happened because she wasn't provided an identification wristband, which led to mistaken identity and the incorrect medicine being administered to her the wristband is given to every patient for identification. When Makena eventually got her Parkinson's medicine, it interacted with the medications that had been given to her incorrectly, leading to hallucinations and anguish. The hospital personnel provided Makena with little information and gave her the impression that she had made everything up.
Table of Contents
RECOMMENDATIONS TO MINIMIZE A RISK TO PATIENT SAFETY. 9
INTRODUCTION
Patient safety, which includes the avoidance and mitigation of damage to patients stemming from medical mistakes, omissions, and adverse events, is a crucial component of providing healthcare. Patient safety in the case study context refers to the degree to which Makena's treatment complied with the requirements for quality, safety, and effectiveness. Risk assessment is an essential stage in making sure patients are secure. It entails identifying possible risks and hazards, gauging the probability that something bad will happen, and formulating plans to reduce or eradicate risks. In the case study, a risk assessment procedure might have revealed the possibility of drug mistakes and misidentifications that might have been prevented by giving Makena an identification wristband. In healthcare environments, both employers and workers have a moral and legal obligation to guarantee patient safety (Carayon,2009). The Health and Safety at Work Act of 1974 in the UK gives companies the means by which to guarantee the welfare and general well-being of their workers and clients. Employers are required to conduct risk evaluations to pinpoint possible risks and dangers, educate employees, and make sure that systems and tools are secure and routinely kept. Employers must evaluate dangers to workers and others, including patients, in agreement with the Management of Health and Safety at Work Regulations of 1999, and take the necessary precautions to reduce those risks. The regulatory foundation for the secure control and delivery of medications in hospital environments is provided by the Medicines Act of 1968 and the Misuse of Drugs Act of 1971. Both employers and workers have a responsibility to make sure that medications are managed, housed, and given in a secure manner, as well as that the proper records are kept. Additional guidelines for professional conduct and responsibility can be found in the HCPC Standards of Conduct, Performance, and Ethics and the NMC Code of Professional Conduct. This report's primary goal is to evaluate the circumstances surrounding Makena's care and to pinpoint areas that could be improved to guarantee patient safety. This report seeks to improve the standard, security, and efficacy of treatment given to people with Parkinson's disease and other chronic conditions by reviewing the incidents, pinpointing the underlying causes, and offering suggestions for development (Brown,2002).
ANALYSIS
FIVE-STEP METHOD
An organized risk evaluation procedure could have benefited Makena's care in the case study that was given. A five-step method for risk evaluation is provided by the Health and Safety Executive (HSE) and can be used in healthcare environments to spot hazards and risks and decide on the best ways to control them (Ramos et al,2020).
- STEP 1: Recognize the risks - In Makena's instance, the risks included the possibility of misidentification due to the absence of an identification wristband and the possibility of prescription mistakes brought on by the administration of the incorrect medicine.
- STEP 2: Determine who might be harmed and how. Makena was the main person at risk, but other patients may also have been in danger if the incorrect person received the medicine.
- STEP 3: Assess the dangers and choose safety measures - This stage involves determining the necessary measures and evaluating the probability of harm and the severity of the results. In Makena's situation, a risk assessment might have revealed the necessity for an identifying wristband, staff education on medication administration safety, and routine medication evaluations to make sure patients are receiving the right medicines.
- STEP 4: Document your results and put them into action - This step entails recording the risk assessment procedure, the dangers and risks that were found, and the steps that were taken to control them. The results of the risk evaluation and the precautions made in Makena's situation could have been documented in her medical records and shared with the medical staff.
- STEP 5: To keep the risk evaluation method current and efficient, it must be reviewed frequently. Regular reviews of Makena's drug regimen, identity, and safety precautions could have stopped the unfavorable events from happening (Gul,2020).
SAFE WORKING
By using the HSE's risk assessment procedure to analyze Makena's treatment, it would have been possible to spot the dangers posed by identifying errors and medication mistakes and take the necessary precautions to avoid them. The risks could have been continuously evaluated and controlled if the risk assessment method had suffered regular reviews and updates. The hazards and risks identified in the case study can have potential impacts on the safe working of various stakeholders, including the employer, employees, and service users.
EMPLOYER: The employer has a responsibility under the law to ensure that its workers work in a secure workplace and that the required policies and procedures are in place to protect service users. Legal action, reputational harm, and financial fines may come from failure to uphold these duties. If it is determined that the company in the case study did not have sufficient policies and procedures in place to avoid the dangers and risks outlined, they may be subject to legal action. If the case is made public, the employer's image may also suffer, which may cause service consumers to lose faith in them (Gul,2020).
EMPLOYEES: Employees have a right to a secure workplace, as well as the instruction and assistance they need to perform their jobs safely. Employees may suffer bodily and psychological damage as a result of unsafe working conditions and insufficient training, which may have long-term effects. Due to the negative events in the case study, the staff members in charge of Makena's treatment may have gone through trauma and mental distress. If an employee is discovered to have violated their duty of care to service consumers, they may also face punishment or judicial repercussions.
SERVICE USER: Users of services have a right to empathetic, effective, and secure treatment that is custom-made to their specific requirements. Lack of safe treatment can have long-term effects on a person's health and welfare, as well as bodily and mental harm, loss of faith in healthcare services, and other negative effects. The hazards and risks found in the case study caused bodily harm and mental suffering to Makena. Her health and welfare may have suffered long-term effects from the unfavorable incidences.
TWO PERSPECTIVES IMPACTS
FIRST PERSPECTIVE:
The dangers and risks mentioned in the case study can have a big effect from the employer's point of view. The financial and legal consequences of failing to provide a safe working atmosphere for workers and service users are one possible effect. If it is determined that the healthcare company in the case study did not have sufficient rules and regulations in place to avoid the dangers and risks outlined, they may be subject to legal action. Financial fines and social harm may follow from this. The employer's image may suffer, which may cause service consumers to lose faith in the organization (Weber et al,2019).
FOR EXAMPLE: If the matter is made public, potential service users might decide to get the treatment elsewhere, costing the company money. It will be resulting as a loss for the company.
SECOND PERSPECTIVE:
The effects of dangers and hazards mentioned in the case study can have a big influence on ice consumers. Physical injury and mental distress are two possible effects. Makena suffered bodily harm in the case study as a result of the incorrect medication being prescribed and misidentification. Due to the unfavorable occurrences, she also felt mental distress. Her health and welfare may suffer long-term effects from these effects. Service consumers may suffer serious consequences if they lose faith in healthcare services (Van et al,2021).
FOR EXAMPLE: service users might become hesitant to seek treatment, which would cause therapy to be delayed and possibly worsen health results.
CONCLUSION
From the point of view of the employer, employee, and service user, the research part of this report looked at the effects of the hazards and risks mentioned in the case study. The legal and financial consequences of failing to provide a secure working environment for workers and service users, as well as social harm and income loss, were addressed from the employer's point of view. Potential effects from the viewpoint of the service consumer included bodily harm, mental suffering, and loss of faith in healthcare services. To protect workers and clients, managers must make sure that secure working procedures are in place.
The case study was subjected to the five-step risk assessment method developed by the Health and Safety Executive, which highlighted the dangers and risks inherent in the medical environment. These dangers and risks included insufficient personnel, patient misidentification, lack of medication, and delivery of incorrect medication. It is obvious that thorough risk analysis and management are essential for avoiding damage to staff members and clients.
The significance of risk assessment and management in assuring safe working conditions in healthcare environments is highlighted in this study. Employers can safeguard staff members and customers of services while avoiding costly and legal repercussions by finding and mitigating dangers and risks (Dennerlein et al,2020).
RECOMMENDATION
RECOMMENDATIONS TO MINIMIZE A RISK TO PATIENT SAFETY.
1. A proper process for patient identification:
- Create and put into action a standard procedure for patient identity that includes giving a wristband for recognition at the time of admission.
- Make sure that every healthcare worker is aware of and adheres to the patient-identifying procedure.
- To make sure the patient identification method is successful, examine and change it frequently.
The danger of patient misidentification and subsequent delivery of the incorrect medicine will be reduced as a result of this suggestion. According to research, mistakes in patient identity can seriously compromise patient safety and result in unfavorable outcomes. Implementing a standardized patient identifying procedure can lower the possibility of patient misidentification and increase patient safety, according to a comprehensive study (Gracia et al,2019).
2. Sufficient Staffing:
- Regularly review and evaluate personnel levels to make sure they are sufficient for patient requirements.
- Staff should receive continuous training and assistance to help them become more competent and confident in handling patient care.
- Implement a method to guarantee that everyone on staff gets regular breaks and downtime to avoid burnout and weariness.
This advice will contribute to introducing the danger of insufficient staffing, which can result in several patient safety issues, such as prescription mistakes and accidents. Insufficient staff levels can lead to lower-quality treatment and higher patient mortality rates. Increasing staffing levels in healthcare environments can enhance patient results and lessen unfavorable incidents, according to a systematic study (Haunch et al,2021).
3. Effective Communication:
- Create and put into place a method for efficient communication between patients and healthcare workers.
- Make sure that every healthcare worker is aware of the value of effective communication and possesses the required skills.
- Provide healthcare workers with ongoing instruction and assistance to help them communicate more effectively.
By following this advice, the likelihood of confusion and poor communication between patients and healthcare workers will be reduced. Research has shown that ineffective communication can result in adverse events, patient injury, and even mortality. Effective communication is essential to ensuring that patients receive safe and effective treatment. The systematic study, and good dialogue can enhance patient outcomes and lessen unfavorable incidents (Musheke,2021).
REFERENCE
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- Carayon, P. and Wood, K.E., 2009. Patient safety. Information Knowledge Systems Management, 8(1-4).
- Dennerlein, J.T., Burke, L., Sabbath, E.L., Williams, J.A., Peters, S.E., Wallace, L., Karapanos, M. and Sorensen, G., 2020. An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic. Human factors, 62(5).
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- Musheke, M.M. and Phiri, J., 2021. The effects of effective communication on organizational performance based on the systems theory. Open Journal of Business and Management, 9(2).
- Ramos, D., Afonso, P. and Rodrigues, M.A., 2020. Integrated management systems as a key facilitator of occupational health and safety risk management: A case study in a medium sized waste management firm. Journal of Cleaner Production, 262.
- Van Biesen, W., Decruyenaere, J., Sideri, K., Cockbain, J. and Sterckx, S., 2021. Remote digital monitoring of medication intake: methodological, medical, ethical and legal reflections. Acta Clinica Belgica, 76(3).
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