Patient Safety: Positive and Negative Effects of Good or Poor Management – Health System Example

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"Patient Safety: Positive and Negative Effects of Good or Poor Management" is an exceptional example of a paper on the health system. This article critiques the failures that are associated with hospital success and good management. In every organization, there are positive and negative impacts that come as a result of good or poor management. Staff Inexperience and Poor Documentation System Staffs at any given organization are very important and need to be well equipped with the organization’ s activities. In the nursing field, there is a need for staff to be compatible from a personality perspective and provide ongoing evaluations on day-to-day activities.

Staff at St. Anthony Hospital lacked experience in treating infants with congenital syphilis that forced the neonatology to call for a local specialist in infectious-diseases. The specialist recommended a dose of penicillin whereby one of the staff called an epidemiologist from the health department whose recommendations were the same. St. Anthony's staff lacked good documentation methods and skills. After the recommendation of drugs, the staff documented the recommendations to the physician’ s form but inaccurately in which, recommendations were made on the progress column. This system failure was due to staff inexperience and poor documentation.

Moreover, the recommendation received from an infectious-disease specialist was not documented. In addition to that, the documentation did not include an administration route for reference purposes. From the way the order was written, the abbreviations were misread thus leading to wrong medication. Due to the staff’ s inexperience and lack of knowledge, the order written overdosed where some different individuals misread it from different perspectives where some abbreviations were seen as additional zeroes. This failure worsened when the computer system failed to give warnings to overdose.

All these complications resulted from poor documentation and lack of experience by the staff that wrote the orders and documented the recommendations.   Failure Precautions Staff education- to avoid such failures in hospitals, there is a need to educate staff on non-formulary drugs and as well on precautions on all drugs. All staff should have adequate information on all medicines from each pharmacy. Unit dose system- the hospital should come up with a unit dose system that is used to show the amount of dose to be taken to avoid overdosing or even underdosing. Standard methods of writing drug orders- hospitals should have standard procedures for writing drug orders for their patients.

All abbreviations should be written the same to avoid misinterpretation and confusion. Responsibility- lines of authority should be established in each hospital and responsibilities within the hospital should be clearly defined and understood by every staff to avoid medication errors. Skilled personnel- the hospital should recruit personnel with sufficient skills and knowledge on medication that enables the hospital to have minimal or fewer cases on wrong medications. Drug orders- pharmacists and other personnel responsible for processing drug orders should have access to clinical information about the patients and maintain medication profiles.

Consequently, the hospital should have a pharmacy department that is responsible for the procurement of all drugs needed by the hospital. This failure might emerge from nursing administration whereby, lack of skilled nurses results in a wrong diagnosis of the disease hence wrong medication. If the nursing administration brought in only the skilled nurses, this kind of failure could not have happened because it started from calling local a specialist who gave recommendations that were misunderstood leading to wrong medication and overdose. According to Lennquist (2012), in most hospitals, the majority of the medical staff experience a failure in the hospital’ s central computer system that enables them to know what is happening within the hospital.

Communication is also very vital amongst staff that makes them aware of whatever is going on. It is also very important to seek clarity where not well understood especially in drug orders and prescriptions that are made through communication. Lennquist emphasizes that; every staff should have access to all information concerning hospital matters. Inconsistent Independent Double Check System Double-check system is a strategy that is used to reduce errors in medication administration.

This independent double-check system brought confusion to pharmacists when the second pharmacist failed to understand what the first pharmacist had done. Since the syringe had been replaced, the order needed to be changed, but the second pharmacist did not check against the order, and, therefore, it differed from the order written. It is important for hospitals to have a consistent independent double-check system that will not result in the confusion of orders against dispense.

Every individual must be keen on orders and expiry dates before dispensing drugs to respective patients to avoid overdosing, underdosing, or a wrong prescription to patients. This failure contributed to a sentinel event by overdosing whereby the first pharmacist checked her work and noticed that the medication in one of the syringes had expired and decided to replace it. On the other hand, the second pharmacist did not recognize the changes and ended up giving it out without checking the order that had been placed.       Precautions to inconsistent independent double-check system Consistent independent double-check system- hospitals should have reliable personnel in checking out drugs ordered, expiry dates, and keen on overdosing and underdosing.

St. Anthony hospital lacked a reliable independent double-check system that resulted in overdosing. Avoid sole reliance on double-checks- sole reliance on double-checks may result in a miscalculation of dose. It is always advisable to have more than one pharmacist in order to correct errors that might have been committed by the other pharmacist.   Introduction of drug therapy monitoring system- pharmacists should participate in the drug therapy monitoring system.

This is to ensure safe and effective use of drugs as well as gaining a wide knowledge by familiarizing themselves with other professionals and other health care units. Pharmacist’ s availability- pharmacists should make themselves available to nurses and prescribers to offer them information and advice needed on the correct use of drugs and medications. Medication ordering system- use of an ordering system in a hospital is very important. Therefore, pharmacists should be familiar with this system and policies that govern the system and procedures on drugs set by the organization for the safe distribution of all medications. No assumptions- the pharmacists should never guess the intention of confusing medication orders.

Before dispensing, if there is any question or unclear order the pharmacist should consult or ask for clarification from the prescriber. Review of orders- unless, in the case of an emergency situation, pharmacists should review the original document of the written medication order before giving out medication. Timely delivery- pharmacists should ensure that medications are delivered to the patients on time after receipt of orders to avoid the expiry of drugs according to hospital policies and procedures. This failure might emerge from a pharmacy section due to a lack of keen observation and consideration on what pharmacists should do on medication orders and other tasks according to hospital distribution policies and procedures.

The pharmacy department should come up with measures to correct this failure for the smooth running of hospital activities. Although some nurses perceive single-checking being the effective way to better use of resources and minimal interruptions to work, research conducted recently has proved that independent double-checking is necessary for reducing errors (Dougherty & Lister, 2011).

Many hospitals have introduced a double-checking system that is consistently applied in practice. This system is effective in detecting administration errors that may be caused by the pharmacists. In contrast, the application of this strategy for all drugs may not be feasible due to time limitations. For the administration of controlled drugs, a second signature is recorded. Although double-checking is always seen to be integral to safe practices, it is an inconsistent practice. Recent research has shown an alternative of double-checking when two nurses independently check a drug and compare their observations, and this found that there was no major diversity in doing it.

The impact of double-checking is very important to pharmacists since it reduces errors at a great range that minimizes cases of the wrong prescription. Conclusion Notably, the failure of some systems in an organization may result in the failure of other systems or the whole organization. It is, therefore, important to the organization to make sure all the subsystems are running well for the smooth operation of the entire organization. Pharmacists are very critical people in the hospital and, thus they need to have wide knowledge in medication methods and procedures.


Dougherty, L., & Lister, S. (2011). The Royal Marsden Hospital Manual of clinical nursing procedures. West Sussex, UK: Wiley-Blackwell.

Lennquist, S. (2012). Medical response to major incidents and disasters. A practical guide for all medical staff. Berlin: Springer.

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