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Responses to the nurses and surgeons “never event” allegations

            The nurses, and the surgeons support of their allegations, to the never event, that it is because of inadequate staff is not justified in any way. In the case study, there is no way that a wrong can be excused with shortage of workforce. This is especially so when it comes to matters to do with human health and life. The case study shows utmost care should be taken before, during and after any procedure in a healthcare facility. The damage caused by such errors that occur in health care facilities could be irreparable and worse still, irreversible.

            The fact that shortage of staff can contribute to occurrence of never events cannot be ignored, but it should not be used as an excuse for allowing them to happen. According to Dallas Medical Attorney, Kay, some or most of these hospitals do not have a plan for assisting those patients who are at risk of falling, and those that do have a plan, more often than not; the staffs do not cooperate with the plan. Therefore, inadequate staffing in the case study is just a lame excuse, especially given the gravity of the situation.

            The patient’s contribution to the occurrence of the never events cannot be ignored either. Some of the patients in desperation to fulfill their urges add to the pressure of the shortage of staff. The patients themselves need to wait for the help of the healthcare personnel anytime they need assistance. Kay suggests that most falls in hospitals occur with patients who are responding to a call of nature. When they press the alarm bell and the nurses fail to respond, or delay, they try to do it by themselves thereby putting themselves at risk. However, it is important to realize that falling is not the only never event in healthcare facilities. Sometimes we have botched up operations that cannot be blamed on inadequate staff.

What is a never event?

            A never event in the case study is an error that should never occur in a healthcare facility. This is because the healthcare is a place where people should be taken care of and not a place where they are exposed to risks. Ken Kizer, MD, who was the CEO of the National Quality Forum in 2001, first introduced the term (AHRQ). The term refers to shocking medical errors (AHRQ) that should never occur. These errors include wrong site surgery, falls among others. These errors signify those events that are clear-cut, serious, they could result in death or even disabilities; and are preventable.

            According to the National Quality Forum, the healthcare never events as of 2011 were twenty nine (29) and grouped into six (6) categories, namely, surgical, product or device, patient protection, care management, environmental, radiologic, and criminal (AHRQ).

The Never Event Discussed At the Meeting

            The never event that occurred at the organization falls under patient protection events category of never events according to AHRQ. There had been a serious case where relatives of a patient had sued the hospital facility. The patient had disappeared from the hospital with no trace. No one seemed to know what had transpired including those on duty at the time the event occurred. Even those that operated the gate could not explain how the patient had passed through the gate under their nose. In fact, no one was certain whether the patient was alive or dead.

            The patient in the case study was undergoing a minor surgery at the facility. He had earlier, before the operation, been diagnosed with mental problems. This was not the first time this patient had tried to escape from the hospital. He was at this time prevented from doing so by the nurse on the night shift that day. For him to escape a day later was unfathomable. He was to be discharged in four days time according to the doctor’s report. At the moment he escaped, he was not strong enough to be released from hospital and needed more check ups. Any strain on his part would be disastrous and could even have led to death. Therefore, he needed extra care even after being discharged.

Examining the validity of the nurses statements

            In order to establish the validity of the allegations by the nurses in the case study, it would be important for the organization to form a task force that would investigate the matter and give recommendations on how to prevent such an occurrence in the future. The task force would be mandated to find out the staff on duty at any particular shift and how many patients on average they need to take care of. The committee would then establish if indeed there was a shortage of staff, to which extent it would be responsible for an occurrence of a never event in the organization. The task force would also find out what the staff on duty could have done to prevent the occurrence of such event.

            Another thing the organization would do is to implement a supervisory mechanism supported by the use of modern technology. The purpose of this supervisory would be to establish to what extent the occurrence of the never event was a result of negligence by those on duty.

Measures to prevent an recurrence of the never event

            In order to prevent the recurrence the organization’s goal would be to make use of the latest technology in order to monitor the events. This would ensure alertness by staff at all times. The technology would also enhance efficient and effective reporting. Kizer and Stegun (2001) however, argue that sophisticated technology is not a prerequisite for reporting. Proper reporting would ensure that any occurrence of such an event is duly reported; the reason for its occurrence is established and dealt with. This would be done in a view to find mitigating measures.

            Proper security checks and surveillance cameras would be placed strategically at the facility to ensure that patients do not move about without being monitored. Those on duty should sign a roll call and the supervisor is alert to ensure that patients are monitored closely at all times.

Approaches that would lead to preventing a “never event”

Total Quality Management (TQM) coined by William Edwards Deming (Legacy Analytics) is the one most likely to prevent the occurrence of a never event. The principals of TQM aim at ensuring that there is conformity to internal requirements (Legacy Analytics). Therefore, those in charge would conform to internal measures set by the organization to prevent occurrence of never events.

            The training of the employees would ensure that they are sensitized on the never events and they themselves are at the forefront of ensuring they never occur. It is to be noted that TQM goal is to reduce errors produced during service processes (Legacy Analytics). In this regard, there would be a great drive towards reducing errors occurring during provision of health care to patients who need it. Those errors that are preventable would thus be avoided through proper internal mechanism set by the organization.

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