Healthcare Incident Reporting and Analysis

The assignment delves into the complexities of incident reporting within healthcare settings. It critically examines traditional methods like root cause analysis and identifies their limitations. The discussion extends to exploring alternative approaches, such as Safety-II and emergent change models, which offer a more comprehensive understanding of system failures and promote proactive safety improvements.

Running Head: NURSING LEADERSHIP 1
Nursing Leadership
By
Institution

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Abstract
Healthcare facilities aim to provide quality services to patients in Australia. Although some
patients are satisfied with the quality of service being provided by hospitals however most of
them are not satisfied due to lot of deficiencies in this sector which leads to poor service
provision. Among the deficiencies are poor monitoring services, information deficiencies,
some board members lacking the capability to monitor the system and inconsistent excellence
(Duckett, Cuddihy, & Newnham, 2016).
Those identified deficiencies are related to the standards, established by the National Quality
and Safety Services standards. Some of the standards in relation to this are National
governance and quality provision, a partnership with consumers, medical safety and
acknowledging and providing response to clinical deterioration in acute health care
(Australian Commission on Safety and Quality Health Care, 2012).

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Part 1: Healthcare Deficiencies addressed by the Review
According to Mitchell (2008), patient safety refers to the preventing patients from
getting harm. Although Australia is among the developed countries in the world, its
healthcare system has been reported to be fragmented, disconnected and frequently failing its
patients Ghosh et al., 2013). Australians pay more in this health sectors, but the care,
obtained is not worth of what they spent. Public hospitals are at worse as they provide
substandard services, however private hospitals having a great reap due to their improved
services. Although the public hospitals have been giving below standards services, most of
the middle-class Australians frequently visit there, due to low cost (Ghosh et al., 2013).
The quality of services can expose patients to adverse effects such as medical errors,
injuries, and hospital-acquired infections etc. (Unbeck et al., 2013). Medical errors occur
when a nurse administers a wrong dosage of drugs or uses a wrong drug on a patient; injuries
occur when a patient falls from bed or due to mechanical fall and lastly hospital-acquired
infections occur when the medical practitioner does not clean their hands off microorganisms,
which are capable of causing infections, or the patient environment is not well cleaned to
reduce chances of infections (Unbeck et al., 2013). Patients who are hospitalized in the public
hospitals are found to be affected by secondary infection after their period of hospitalization
elapses. This causes them to have an extended period of stay.
Medical practitioners, nurses, clinicians, registrars and many others, have a
responsibility of controlling these adverse effects. The practitioners, being careful and
cautious to how the patient is cared for helps in controlling the adverse effects (Dubois &
Singh, 2009). Clinicians and other medical practitioners should understand the impact of
adverse effects on patients, which is usually detrimental to the caretakers and patients too.
This should be a driving force to their adequate care that they must give to patients.

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System managers together with policymakers have a responsibility to reduce the
impact of adverse effects. They have a responsibility as leaders to help hospitals benchmark
against each other, to give incentives to clinicians and nurses which will help them prioritize
and put more effort on the safe care provided to patients (Dubois & Singh, 2009). Without the
help of leaders, it will be difficult for the health practitioners to penetrate and give the safe
care required due to lack of information, resources, and incentives.
The adverse effects experienced in most of the hospitals are attributed to various
factors. These are the healthcare deficiencies. They explain what is not done right in the
hospital system leading to the increased adverse effects. From the review, the following are
some of the healthcare deficiencies that were identified.
Healthcare Deficiencies
From the review by Duckett et al. (2016), there are various healthcare deficiencies
that are experienced in the Australian healthcare facilities, especially in the public hospitals.
Among these healthcare deficiencies mentioned in the review are: Hospitals cannot access
critical information, lack of mature systems monitoring safety and quality, some boards do
not have the necessary capability to monitor the safety and quality of their hospitals; instead,
the hospital is capitalised with pockets of excellence and not consistent excellence (Duckett
et al., 2016).
Lack of Effective Incident Reporting Systems
Information is a key element in hospitals that have an aim of providing safety and
quality of services. Lack of information to both the clinicians and the entire hospital may lead
to conflicts and medication error (Hussey et al., 2009). Due to lack of information serious
issues such as overdosing, wrong medication administration and wrong treatment to the
patient can occur. So, communication need to address properly (Hussey et al., 2009).

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Hospitals need to develop tools to communication effectively and to avoid the
development of the adverse effect to patients. For instance, the development of clinician
guidelines can be very useful as it contains information of various diseases, how to diagnose
them and the correct treatment to be given to the patient. Many hospitals have had such
guidelines, but those that are outdated; too complex or they lack credibility (Duckett et al.,
2016). The ministry of health in Australia then has a challenge of developing new clinician
guidelines which are more advanced, up to date and easy to understand, which can only be
achieved by team of chief clinicians coming together to develop, analysing, assessing and by
reviewing the system(Hussey et al., 2009).
According to Braithwaite et al. (2008), effective information reporting system
regarding hospital incidents plays a critical role in safety management in the healthcare
industry. From the Duckett et al. (2016) report, it can be identified that patients that are
suffering from conditions that are preventable is still a major issue despite having an incident
reporting system in the hospital. Although the incident reporting system has been
implemented, effective in-depth analysis on the cases being reported have not been done as
identified by Anderson and Kodate (2015). The review by Duckett et al. (2016) notes that
400,000 incidents have been reported but no systematic analysis has been done (p. 107). The
review states that the Victorian Health Incident Management System was established for
learning purposes and does not play an oversight role (Duckett et al. 2016, p. 107). It is also
noted that the report does not support learning as well. This is a reflection of the fact that the
hospital did not appoint staff responsible for managing, analysing, and using the collected
data to implement improvement in the hospital (Duckett et al. 2016, p. 107). The review also
notes that the system is poorly designed and complicated and is cumbersome to the data entry
individual and the analyser. Due to these factors, there is doubt whether the information
recorded in the system truly reflects the hospital incidents (Westbrook et al., 2015).

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According to a research by Macrae (2015), incident reporting has shifted its focus to
categorization and data collection which does not contribute significantly to successful
learning experience. Sujan, Huang and Braithwaite (2017) state that poor utilization of
incident reporting systems, the fear of taking responsibility, and ineffective feedback loop are
some of the barriers to effective incident reporting system. A study by Peerally et al. (2017)
suggests that the incident of companies forgetting their lessons is intrinsic to the failure of
doing a root cause analysis that aims at analysing incidences and come up with mitigation
strategies.
Lack of Mature Systems to monitor Safety and Quality
Australian health care systems have been regarded as immature monitoring systems
by the various researches (Duckett et al., 2016). These immature monitoring systems make it
hard for an investigation, when an awful event has occurred (Duckett et al., 2016). According
to the review by Duckett et al. (2016), the Victorian hospital developed NSQHS standards
which are evidence-based and captures essential safety and quality areas. However, the
monitoring process is poorly designed; hence, making it hard to determine whether the
standards are met (Duckett et al., 2016, p. 80). A monitoring system that is partially
functional in the hospital, the management unable to acquire information necessary to
understand the frequency and pattern of harm. Thus, that will arise an inability of the hospital
to utilize and analyse the data, moreover failing to fulfil its system management role. To
avoid all these implications, there is need to upgrade the monitoring systems in every hospital
and proper training to the staff (Hill et al., 2010).
According to Duckett et al. (2016), the standards of quality and safety should always
be available throughout the year and should be consistent with the clinical practices (p. 80).
Monitoring systems in every hospital need to be upgraded to an advanced level. The system
must be upgraded in such a way that it can analyse both the quality of services and safety

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given to patient. The upgrading of the systems can be done at intervals of five years. An
analysis interval of five years is important as it gives room for one to set new goals for safety
and quality. Training should be given to the staff at the regular intervals (Hill et al., 2010).
Poor Governance by Board Members due to Knowledge Gaps
Hospital boards play a vital role in making sure that the safety and quality of hospital
services are well maintained and adhered to. They are responsible for setting the tone of
corporate culture of an organization (Duckett et al., 2016, p. 24). The review by Duckett et al.
(2016) identified that there are gaps in governance and oversight by the boards which have
led to serious failures. The review found out that there are failures in clinical governance all
the organization levels (Duckett et al. 2016, p.25). For instance, the review identified that the
boards’ appointment process has some flaws (Duckett et al., 2016). One of the weaknesses of
the appointment process identified is that the appointees and applicants were supposed to
assess their competencies on their own (Duckett et al. 2016, p. 25).
The review established that there were significant gaps in knowledge and activities
(Duckett et al. 2016, p. 26). An academic research by Bismark et al. (2014) revealed that
knowledge and activities gap exist among the board members, especially in the rural regional
boards. According to research by Bismark, Walter and Studdert (2013, p. 3), it was
established that in every five Victorian boards, there is one who does not put quality
performance as their primary agenda on their meetings and about 50% did not offer training
on quality to their team. There are also significant information challenges in the Victorian
boards (Duckett et al., 2016, p. 26). The review established that there gaps in capacity
mainly in the rural hospital boards (Duckett et al. 2016, p. 26). The boards are also resistant
to change; both full-time and part-time doctors could not agree on any attempt to influence
their manner of executing their duties (Duckett et al. 2016, p. 26). As stated by Conway

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(2008), the boards need to identify opportunities that would drive improvement to the
existing systems and ensure that the changes are implemented.
In line with the governance issues, the Duckett et al. (2016) review stated that
majority of the boards could not understand their roles in governance of the clinics and could
relate the roles to financial responsibility (p. 27). Some members of the board, however,
believe that do not need to use the same diligence in the governance of clinics (Barden et al.,
2011). The review further established that safety and quality issues were not often discussed
in meetings (Duckett et al. 2016, p. 27). All these are known to be the responsibilities of the
board members as they help the hospital in accounting for safety and quality of care provided
by the hospital.
National Safety and Quality Health Service Standards (2012) related to the Deficiencies
Poor management within the health care systems in Australia resulted in low levels of
maintaining safety and quality care within the hospitals. This led the Australian commission
on safety and quality in healthcare system develops a National Safety and Quality Health
Services Standards in 2012. These standards are to guide healthcare facilities in ensuring that
minimum safety and quality are met in every institution. In total, the number of National
Safety and Quality Health Services Standards that were developed are ten. These standards
have a role they play in ensuring the HealthCare systems run smoothly. According to
Australian Commission on Safety and Quality Health Care (2012), these standards include:
Governance for safety and quality in healthcare organizations, partnering with consumers,
Preventing and controlling healthcare-associated infections, medication safety, patient
identification and procedure matching, clinical handover, blood and blood products,
preventing and managing pressure injuries, recognizing and responding to clinical
deterioration and preventing falls and harm from falls. All the eight of the standards are
interconnected with the first two standards.

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From the healthcare deficiencies that were revealed in the review by Duckett (2016),
there is a relationship that exists with the set standards. Among the National Safety and
Quality Service Standards set, there are five of them that relate to the healthcare deficiencies
provided in the review. These are: Governance for safety and quality in healthcare
organizations, partnering with consumers, medication safety, patient identification and
procedure matching, recognizing and responding to clinical deterioration.
Governance for Safety and Quality in Healthcare Organizations Standard
This is the first standard of the NSQSS, which broadly covers the rest of the
standards. The leaders of the healthcare facilities employ governance in setting, monitoring
and improving the performance of the organization (Australian Commission on Safety and
Quality Health Care, 2012). The governance provided will help in the development of
performing organizations. The aim of this standard is to ensure the provision of united
governance which will help to improve the reliability and the quality of patient care. The care
of the patients is the centre of it all. To achieve this, the standards provide criteria which can
be used by hospitals to ensure safety and quality achievement. They include: clinical practice
in which the clinical officers are trained on the quality of service to give to the patients,
performance and skills management in which the employees and the management have the
required skills and qualifications to provide the care service, incident, and complaint
management where the incidences and complaints reported by patients are analysed and the
required steps that were taken (Australian Commission on Safety and Quality Health Care,
2012). This standard is seen related to some of the healthcare deficiencies that are pointed out
in the review. These healthcare deficiencies include information deficiency, board members
lacking the capacity to monitor safety and quality and immature systems for monitoring
safety and quality (Australian Commission on Safety and Quality Health Care, 2012). The
standard address ways in which healthcare facilities can implement to help in managing the

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deficiencies that are mentioned above. Clinical practice as a criterion helps in solving
information deficiencies. The clinical officers are trained and given full skills required for
care provision, performance and skill management as a criterion that is used in solving the
lack of knowledge by some boards in monitoring safety and quality. The direct relationship
exists between this standard and the deficiencies that are mentioned; it helps solve the
deficiencies.
Partnering with Consumer Standards
This is a standard in which the leaders of the healthcare organizations implement
systems that will help them create a good relationship with the carers, patients and other
consumers, which will help boost safety and quality (Duckett et al., 2016).This standard help
to create health services that are responsive to carers, patients, and other consumers.
Clinicians, management and any other medical practitioners within the hospital have to put an
effort in order to achieve this (Duckett et al., 2016). This standard is related to information
deficiencies, where consumer partnership in service measurements and evaluation. Carers,
patients, and other consumers receive information on healthcare performance and contribute
to the ongoing monitoring, analysis and evaluation of the performance. This will help in
quality improvement.
Medication Safety
This is the fourth standards of National Safety and Quality Service Standards in which
the leadership of the healthcare facilities implements various systems to help reduce the
reoccurrence of medication incidents (Duckett et al., 2016). It also helps to improve the
quality and safety of the medicine used. This is done by the organization having a safety
mechanism in which they are able to prescribe, dispense, supply, administer, store,
manufacture, and monitoring of the medicine reactions. This helps in ensuring that patients
are given right dosage. Patient’s information is also well documented that helps to ensure the

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right patient is given the right medication (Duckett et al., 2016). This standard still relates to
information deficiency, where clinicians need to be updated on the right way of administering
medication. The institution should come up with a way of updating, and as directed by this
standard, clinicians should be taught on how to prescribe, dispense, administer, store and
finally follow-up in case of a drug reaction (Duckett et al., 2016).
Recognising and Responding to Clinical Deterioration in Acute Healthcare
This standard entails the health organizations establishing and maintaining systems
which will help in recognizing and responding to clinical deterioration. These recognition and
response systems are used by most clinicians and other medical practitioners to help maintain
safety and quality (Duckett et al., 2016). The patients' health is recognized promptly, and the
required actions are taken immediately. This standard can be achieved by establishing
recognition and response systems which will help monitor when a patient undergoes clinical
deterioration and thus giving the necessary care. Communicating with the families and carers
of these patients will assist in establishing a new and a great way of care provision. This
standard is related to the deficiency of good monitoring systems within the hospitals. A poor
monitoring system will not indicate patients with clinical deterioration and thus will affect the
general care provision (Duckett et al., 2016).
Conclusion
Although most of the Australian boost of their health sector, there is no doubt that
several healthcare deficiencies are realized. From the review that was analysed in this paper,
several deficiencies are realised and they include: information deficiency or lack of critical
information to the clinicians and hospitals, some of the board lack ways to monitor systems
on safety and quality, lack of mature systems to monitor safety and quality and lack of
consistent excellence (Duckett et al., 2016). These deficiencies show great relation to the
National Safety and Quality Health Services Standards. The standards give a direction on

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how these deficiencies can be overcome to ensure smooth working within the healthcare
facilities. Every individual within the health care has a responsibility to ensure that safety and
quality are met. Clinicians, doctors, nurses and other medical practitioners together with the
patients and the care providers have a responsibility to work as a team to ensure that safety
and quality are met within the institution.
Part 2: A Plan to Improve Ward Culture relating to Reporting Safety Issues
Communication among all health workers within a healthcare institution is very much
important. It plays a bigger role in ensuring that there is an achievement of safety and quality
in the institution (Macrae, 2015).When an effective communication plan or policy is
implemented in a health institution, then there will be reduced or no cases of adverse effects
(Macrae, 2015).
Many hospitals have been reported severally where the flow of information within
the hospital is altered. The clinician consults their colleagues concerning any issue arising
despite the availability of the improved electronic systems of communication management
(Macrae, 2015). The systems created within the hospitals contain all the necessary
information required as far as a procedure is concerned. Consulting a fellow clinician will
result in the inappropriate handling of the patient and thus leading to the adverse effects that
are being fought to be eliminated.
Poor communication within these healthcare institutions is attributed to several
factors. These are factors that predispose the entire staff of the healthcare facility to a poor
communication system. Among these factors we have: culture of the hospital, the way the
management has trained his staff is how they will carry themselves within the institution, care
has to be taken by the management to ensure installation of proper communication routine to
the staff which can always be withheld (Macrae, 2015). Poor communication can also arise as
results of nature of the available communication infrastructure, the nature of the work

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undertaken and the practices that are routinely undertaken by the individuals (Macrae, 2015).
All these factors contribute to determining how well the flow of information can be done in
an institution.
For the purpose of discussion, an emphasis will be put in the change management
theories that help in transforming an organization.
Change Management Theories
Kurt Lewin’s Three Phase Model
Kurt Lewin’s three phase model, sometimes known as the planned change model,
refers to a change that is spearheaded by an organization (Shirey, 2013). In this theory, an
organization identifies an area that requires a change and work towards implementing the
same. In this theory, group dynamics plays a crucial role in decision making. The change to
be implemented in an organization is communicated to all members after which each one of
them participates in implementing it. Under this theory, change occurs in three phases;
unfreezing, change, and refreezing (Shirey, 2013). The first phase, the unfreezing step,
involves preparation of the organization to accept and understand the necessity of the change.
This involves breaking down of the status quo prior to building up of a new way of operating
(Shirey, 2013). This can be achieved by convincing the members within the organization why
the existing system needs to change. In preparing the organization for change, one has to
challenge the culture, values, behaviours and beliefs of the organization. One has to prepare
himself to change the current foundations and ensure the change is effective and touches on
the organizational goals. The second phase is the change. In this stage, people start to believe
and act in a way that supports the change being introduced (Hartzell, 2017). Kurt Lewin’s
theory acknowledges that change is a process and, therefore, cannot happen overnight
(Hartzell, 2017). This stage is sometimes referred to as the transitioning or moving phase.
This phase is where implementation of the change is done. It is where the change is

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actualized. The final stage is the refreezing phase. This phase involves reinforcing,
solidifying and stabilizing the change (Hartzell, 2017). The changes that have been made on
the goals, processes, and structure of the organization are refrozen and set as the new norm
(Shirey, 2013). This step is essential as it ensures that people do not revert back to the
traditional ways before the change was implemented. It is a crucial step to ensure that the
change is not lost but rather, accepted and embraced by the entire organization. Without this
phase, there is a high probability that people will go back to their traditional ways of thinking
(Hartzell, 2017).
Emergent Change
The emergent change model is inspired by the complexity theory and organizational
learning theory (Wirth, 2014). The model has a more holistic view on the change and puts
emphasis on creating the capabilities that enable an organization to withstand environmental
pressure towards a change (Wirth, 2014). The emergent approach recognizes change as an
ongoing process. The emergent change model considers a change as an attempt by an
organization to amend an existing system that was previously established in response to
environmental influences and organization intentions (Wirth, 2014). This implies that a
change is unpredictable since environmental influences can change anytime. The
organizational board should continuously change the systems to align them with the
environmental changes.
Implementing a change requires one to create a willingness to change. For the change
to be effective, it must be accepted by all members within the organization and must be
willing to embrace it. When an organization wants its employees to shift from one system to
an unknown system, it must convince and win people’s minds so that the change can be
accepted and become effective. It is apparent that a change can face resistance from some
members and the organization can lose from this. It is, therefore, essential for an organization

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to understand that stressing on the positive aspects of a change is not the only factor that will
make the change to be accepted (Burnes, 2009). As seen from the previous discussion, both
Lewin’s theory and the Kotter’s emergent change theory recognize the fact that a change can
easily be accepted by making people understand the unsuitability of the existing system than
by stressing on the suitability of the future system.
Implementing the Change of Reporting Culture on Ward
The Kotter’s eight step model of change management can be used as a guiding
principle in implementing the reporting culture change in the ward. Each step acts as a
principle for making the change comes into reality and the steps are described below. The
first step is to create a sense of urgency (Appelbaum et al., 2012). As discussed in the review,
despite the good efforts by employees, preventable harm still occur to patients. This is critical
information for establishing a sense of urgency for change. All employees should be made
aware of the need for change. After creating an urgency fir change, the next step is to create
a guiding coalition (Mulder, 2014). This step requires that a team establishes itself with the
changes to be implemented. The step requires that all employees make efforts in making a
constructive approach to change (Mulder, 2014). In the case of the Victorian hospital, the
manager can build a team and share governance responsibilities. The nurse leaders will play a
crucial role in the change implementation since they are the heads to which the rest will be
seeking advice from. The third step is to create a vision for change. The vision will be set
based on the review by Duckett (2016). The change strategies will be communicated to the
team members so that actions can be taken. Formulation of a clear vision is important for
everyone to understand what the organization wants to change. The goals adopted by the
employees will be linked to the strategies so that the organizational goals can be realized. The
next step is to communicate the vision. This step is aimed at creating support among the
employees. This will be achieved by sharing the information about the vision at every step of

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the change process. This will ensure that the vision is adopted by the entire organization.
Removing obstacles is the fifth step in transforming an organization according to the Kotter’s
8-steps model (Mulder, 2014). Before any change becomes fully accepted, all obstacles that
might hinder the vision must be removed. When all the employees can access information
and all the necessary resources and learning and growth opportunities, an organization can
achieve productive power (Manojlovich, 2007). There is need to establish a strong
relationship among all employees at all levels in the organizational hierarchy. In the ward, the
manager can, on regular basis, provide supportive feedback on employees’ performance. This
will act as a motivation and will help the rest of the employees to work hard towards
achieving the change. The positive feedback on performance will help in building strong
relationship among the staff in the ward which will be based on mutual trust and
understanding, and ensure opportunities for growth and learning are available for the staff.
The next step is to create short-term wins. According to Mulder (2014), there is nothing that
can motivate an individual more than success. It is essential to develop short-term goals so
that the members of the team can have a coherent idea of what is happening. According to
Burnes (2009), it is necessary to maintain a momentum for change through emphasizing on
the desired values. This can be done in form of a financial benefit such as a bonus to an
employee’s monthly stipend or in form of a promotion. This will help employees to have a
positive attitude towards the change initiative. Another step is to consolidate improvements.
According to the Kotter’s 8 steps model, many change initiatives fail because of early victory
declaration (Mulder, 2014). A change is a slow process and should be incorporated in the
overall organizational culture. The goal to have zero harm incidents on patients will require a
continuous approach to improvement. This will have a significant influence on the outcome
evaluation and streamlining of the strategies. Enough resources will need to be allocated to
the nurses and other employees to ensure that their competencies, skills, and knowledge base

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are developed continuously. The organization will have to keep on looking for improvements.
The last step is to anchor the changes. According to Mulder (2014), a change will be
considered as organizational culture only if it has been incorporated as part of the
organizational core values. It will take a while for the culture of excellence in safety to take
effect. It is, therefore, essential for the management to exercise visionary leadership in order
to help in maintaining the culture and develop it for the betterment of the organization. The
employees will be expected to promote the change.
Conclusion
The Victorian hospitals require changes in their systems in order to realize the safety
goals of the patients. A culture of openness to learning should be adopted instead of
cultivating in a culture of blames. Nurses and other healthcare practitioners should be
empowered and be involved in all the change initiatives so that they can feel appreciated. The
Kotter’s 8 stage model of transformation and change management is a crucial tool that helps
nurses to break down the entire change process that a nurse may need to implement at the
ward level.

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