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Poor risk management in a healthcare organization is something nobody wants to see, especially when there are patients involved. Poor risk management cannot only hurt the organizations reputation, but it can also take away the trust factor that once was there. When asked to write a discussion post on three examples of how poor risk management impacts a health organization, the first thing I thought of was the failure of communication. Communication is vital no matter what situation you our in. There is a difference between effective communication versus ineffective communication. “Communication, commonly seen as an innocuous component of healthcare delivery, is a real and dangerous threat to patient safety if handled poorly” (Youngberg, 2011, p. 431). Effective communication is clear and concise, whereas ineffective communication is not understandable and does not get the message across to the individual you are directing it at. The problems arise when ineffective communication is not clearly understood, and numerous mistakes get made. “In a study by Awad et al., 36% of communication failures were found to result in visible effects on system processes including inefficiency, team tension, resource waste, work-around, delay, and patient inconvenience” (Youngberg, 2011, p. 432). With all that being said, we cannot forget about the numerous situations that involved patient injury or even death because of a lack of improper communication.
Education and training are another element that presents itself in the errors we see in communication. Physicians, nurses, or healthcare employee’s all receive different training in regard to communication. Very rarely, all the staff in the healthcare organization will receive the same training. A physician might have been taught to approach a situation in one type of way, while the nurse will be shown another. We can assume that with different style of training in communication, problems will arise. “Doctors are taught to be concise and get to the “headlines” without haste, while nurses learn to be broad, narrative, “paint the big picture,” and not make diagnosis when providing clinical descriptions” (Youngberg, 2011, p. 434). The lack of training will also play a part when it comes to handling errors that happen in a healthcare organization. How one physician deals with a medical error may not be the way another does, leading to miscommunication.
Thirdly, limiting work hours worked. We all know that when we work a long day, we our just tired and we tend not to “care” as much as we did when we first started our shift. It is not uncommon to hear that both physicians and nurses work long hours, especially in a hospital. Residents are now limited to working 80-hour weeks due to fatigue/burnout. The Accreditation Council for Graduate Medical Education enacted duty-hour limits for both resident education and related patient care because of this fact alone. “The duty -hour standards were adopted out of concern that fatigue resulting from excessive hours for residents jeopardized the quality of care and subjected them to working environments that were not conducive to learning” (Youngberg, 2011, p. 435). However, by limiting the hours that they are allowed to work caused other problems such as an increased volume of transfer patients. With the increase of transfer patients came the increased chance of communication errors, which in turn increased the patient handoffs.
This may seem like a scary situation, especially knowing that it is dealing with patient care, but there is always a brighter side to everything! It is never too late to implement change and set standards in place that everyone needs to follow. “Through the use of training, culture change, dismantling of hierarchies, improved forms, mandatory debriefing, personality awareness, redundancy, or critical language, communications that occur at the time of patient handoffs can be improved” (Youngberg, 2011, p. 440).
Youngberg, J. B. (2011). Principles of Risk Management and Patient Safety. Burlington, MA: World Headquarters.
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