High Reliability Organizations Paper
1. Describe a broken process that you have observed or worked with that you believe was (or is) unsafe for patients. What happened?
One broken process that I have observed that was unsafe for patients was related to medication administration in a hospital. The medication administration process involved multiple steps, including physician ordering, medication dispensing, medication administration, and documentation. One particular step where I noticed a breakdown in the process was during medication administration. Nurses were required to check patient identification, verify medication orders, and administer the medication. However, there were times when nurses were interrupted during the administration process, which could result in medication errors or omissions.
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.
In a high reliability organization with a Just Culture, the broken medication administration process would be addressed through a combination of the following characteristics and core principles:
- Preoccupation with failure: The organization would have a strong focus on identifying and addressing potential failures in the medication administration process, such as interruptions during medication administration.
- Reluctance to simplify: The organization would recognize the complexity of the medication administration process and the potential for errors or omissions at any step.
- Sensitivity to operations: The organization would prioritize the needs of frontline staff who are responsible for medication administration and work to support them in their efforts to ensure patient safety.
- Commitment to resilience: The organization would work to develop systems and processes that can adapt to changes and unexpected events in the medication administration process, such as interruptions or emergencies.
- Just Culture: The organization would strive to create a culture where staff feel comfortable reporting errors and near-misses without fear of retribution, and where leadership uses this information to make improvements to the medication administration process. Additionally, the organization would investigate reported errors and near-misses to identify the root cause of the problem, rather than simply blaming individuals.