Describe a broken process

1. Describe a broken process that you have observed or worked with that you believe was (or is) unsafe for patients. What happened?

2.What leadership style was being used?

3.Using the characteristics, core principles of high reliability organizations, explain how that same problem would be addressed in a high reliability organization that has a Just Culture.


Describe a broken process

  1. Broken Process in Healthcare:

As a language model, I haven’t directly observed any broken process in healthcare. However, I can describe a broken process in healthcare that has been reported in the literature. One of the broken processes in healthcare that can lead to patient harm is medication errors. The Institute of Medicine (IOM) defines medication errors as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.” Medication errors can occur at any point in the medication use process, from prescribing to dispensing and administration.

One of the common medication errors is related to the prescribing process. For example, a physician may prescribe a medication at a dose that is too high or too low for the patient’s age, weight, or medical condition. Alternatively, a physician may prescribe a medication that interacts with another medication the patient is taking. These errors can result in adverse drug events (ADEs), which can lead to serious harm, including hospitalization and death.

  1. Leadership style:

The leadership style that may contribute to medication errors in healthcare is autocratic leadership. In an autocratic leadership style, the leader makes decisions without consulting or involving others. Autocratic leaders may not listen to feedback from subordinates and may not provide opportunities for them to participate in decision-making. This leadership style can lead to a culture of fear, where subordinates may not report errors or near misses, which can contribute to a lack of learning from mistakes and a lack of improvement in the process.

  1. High Reliability Organizations:

A high reliability organization (HRO) is an organization that operates in complex, high-risk environments, yet has an exceptional safety record. HROs are characterized by their ability to anticipate and manage unexpected events, and their commitment to continuous learning and improvement. The core principles of HROs are preoccupation with failure, sensitivity to operations, reluctance to simplify, commitment to resilience, and deference to expertise.

To address medication errors in a high reliability organization that has a just culture, the following strategies can be used:

  1. Engage all members of the healthcare team in the medication use process, including physicians, nurses, pharmacists, and patients.
  2. Use evidence-based guidelines to standardize the medication use process.
  3. Create a culture of reporting and learning from errors and near misses, without blame or punishment.
  4. Use technology to improve the medication use process, such as computerized physician order entry (CPOE), barcode scanning, and electronic medication administration records (eMARs).
  5. Monitor and measure the medication use process to identify areas for improvement and track progress over time.

In conclusion, medication errors are a common and potentially harmful problem in healthcare. Autocratic leadership may contribute to medication errors by creating a culture of fear that discourages reporting of errors and near misses. To address medication errors in a high reliability organization that has a just culture, the core principles of HROs can be applied to create a culture of learning, improvement, and collaboration.


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