Improving Leadership and Patient Safety in the Emergency Department

This article discusses the importance of improving leadership and patient safety in the emergency department. It explores the use of fishbone diagrams to identify areas for service development and suggests training on effective leadership styles and awareness workshops on high-quality and safety practices. The article also highlights the need for better conflict management and communication skills within the emergency unit. Additionally, it emphasizes the importance of fall risk assessment and medication safety competence to promote patient safety.

Running head: NURSING
NURSING
Name of the Student:
Name of the University:
Author Note:

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Poor
service
quality
Conflict within ED
Inefficient leadership skills
to manage conflicts
Poor medical
documentation and
reporting errors within ED
High risk of falls within
ED
Poor Patient Outcome
Introduction:
The healthcare sector is regarded as one of the most dynamic sectors that requires
continuous improvement and integration of innovation so as to facilitate quality in terms of
service delivery. Our clinical area of specialization involves working within the emergency care
unit which is characterized by a strenuous and busy work schedule and requires the effective
functioning of a multidisciplinary team of care professionals so as to ensure a positive care
outcome. Based on our domain of specialization we would like to use the fishbone diagram in
order to identify two critical areas that need service development in order to promote positive
outcome. As stated by Bashkin et al. (2015), the fish-bone diagram assists professionals to
identify and categorize the potential problems that hinder the smooth functioning of a process
and accordingly assort relevant solutions.
Fig: As created by author

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Therefore, on the basis of the fishbone diagram, the first issue would comprise of service
development thorough training on effective leadership style so as to manage resistance and
conflict within the emergency unit so as to create a high performance nursing team. The second
would comprise of imparting knowledge through awareness workshops about the development
of high quality and safety within the workplace. The rationale for the choice of the topics can be
mentioned as their strong correlation with the work atmosphere and work process within the
emergency care unit.
Building high performance nursing team:
Conflict can be defined as a cumulative outcome of differing expectations, backgrounds
or communication styles among a team of professionals. Conflict within the emergency
department can occur between nurses and patients or family members, consultants,
administrative staff or the multidisciplinary team of professionals during the decision making
process. Research studies suggest that adapting a transformational leadership style can positively
help in conflict resolution (Chan et al., 2013). A research study suggested that managers who
exhibited the transformational style of leadership managed to resolve conflicts by integrating the
obliging style of conflict management (Saeed et al., 2014). Transformational leadership can be
defined as the leadership style where the leader works collectively with a team and identifies a
needed change in the process. Upon identification of the change, the leader creates a vision so as
to guide the team to realize the change through motivation. On account of excessive workload
and multitasking, emergency departments are susceptible to medical errors in relation to
incorrect medication management and reporting. The problem is serious pertaining to the adverse
impact it can cause on the wellbeing of the patients. However, as per Ehsani et al. (2013),
nursing leaders must respond to episodes of medication error constructively rather than putting

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up an autocratic or oppressive leadership style which has been studied to affect the performance
outcome negatively. As stated by Emerg (2018), leadership in emergency medicine is extremely
challenging as the leadership style cannot be mastered with the application of a single leadership
model. Effective communication, emotional resilience and organized thought process to manage
the coordinated functioning of the multidisciplinary team while working on a crisis scenario can
help in promoting positive outcome. Further, Seow (2013), suggested that being aware about the
team dynamics and building a strong rapport with the team can facilitate better acceptance of
change and improved communication resolution.
Therefore, clear identification of the crisis or the chaos, finding a solution and being able
to motivate the team to follow a mutually agreed emergency protocol can help in resolving a
crisis or a chaotic situation within the emergency department. In order to foster effective
strategies of conflict management within the emergency unit, nurses and allied care professionals
must be educated about conflict management and collective team working. Also, workshops on
effective communication can be conducted in order to improve the communication skills so as to
promote improved inter-professional communication. The performance post workshop would be
evaluated on the basis of observation against the key performance indicator tools such as degree
of improvement in handling stressful situations, ability to manage conflict and improvement in
terms of communication ability.
To improve high quality and safety in the workplace:
Emergency care units are subjected to a busy work schedule with excessive patient load
and limited nursing staff present to manage the patients. The scenario is common across most of
the healthcare organizations in Hong Kong. (Sickbert-Bennett et al., 2016). Emergency care units

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are also subjected to a number of risks pertaining to falls, medication preparation or
administration errors and faulty physical assessment. According to Guthrie, DO and Hochman
(2018), crowded and busy emergency departments are susceptible to increased risk of falls. Also,
as stated by McErLean, James and Hughes (2017), falls account for a major proportion of
morbidity and mortality of the patients within a healthcare setting. The emergency unit deals
with patients who are placed at an acute and hyper acute stage of physical and mental illnesses.
In general falls occur due to symptoms such as confusion and disorientation, impaired gait,
intoxication or tripping over furniture. In addition to this, falls could result in adverse health
outcome such as fractures and at the same time lead to an increase of medical expenditure in
relation to extended hospital stay. Also, Ehsani et al. (2013), stated that medication error in
relation to preparation of correct dose, administration through correct route and confusion while
handling ‘look alike sound alike’ medication is common within the emergency department. It has
further been mentioned that reporting errors such as incorrect documentation of medical history
or missing out on physical assessment details is also common within the emergency department
due to patient overload and multitasking. Patient safety is integral in the field of healthcare
system so as render quality services that promote positive patient outcome. Medication or
reporting error leads to a compromise with the patient safety and triggers a multitude of negative
implication on the health of the patients. The implication can either result in the emergence of a
new condition due to an adverse allergic reaction or could even lead to a fatal outcome such as
death.
Therefore, it is pivotal to ensure patient safety within the emergency care unit so as to
acquire positive patient outcome and increased patient satisfaction. As stated by Muray, Belanger
and Razmack (2018), falls can be prevented within the emergency department by conducting a

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fall risk assessment of the patients. A number of tools such as MEDFRAT and KINDER1 fall
risk assessment tools can be used by care professionals within the emergency unit in order to
avoid risks associated with falls. Further, the evidence base suggests that complying with fall
prevention strategies within the emergency department can help in reducing the prevalence of
falls. The risks in association to medication and reporting error can be minimized with better
management of workload and improved knowledge about pharmacology and medication safety
competence standards.
Therefore, we believe that acquiring an in depth knowledge about the risk factors such as
falls and medication and reporting error can guide nurses to improvise on their professional
practice so to promote improved patient safety. According to our perspective, organizing training
workshops and refreshment courses to improve the pharmacological knowledge can help in
stimulating better understanding about patient medication. Also, imparting education through
training about medication error, their adverse implication and medication safety practices can
help in reducing fatal outcome and promote quality in terms of service standards. Also, nursing
professionals can be encouraged to share medication error incidents through nursing forums in
order to develop a better understanding about the nature of medication error and adapt
appropriate precautionary measures so as to promote patient safety. We strongly feel that
implementation of patient safety guidelines within the hospital can help in ensuring patient
safety. Also, effective monitoring of compliance and follow up through surveys and inpatient fall
and medication errors can significantly improve the quality of care provision by the concerned
healthcare organization.
Conclusion:

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Therefore, to conclude, it should be mentioned that in this paper we have critically
described about the two professional areas which when improved through the proposed
recommendations can help in service development. The two areas have been selected as
developing effective leadership and ensuring patient safety. Emergency department are
susceptible to chaotic situations which might involve, tackling situations such as managing
chronic respiratory distress, cardiac arrest or a life threatening situation. It is extremely important
to ensure that the leader remains calm in such situations and is able to effectively communicate
with the team so as to positively tackle the situation. Further, increased knowledge about
pharmacology and patient medication as well as fall risk assessment can help in promoting
patient safety and at the same time improve the quality of service provision by building an
effective nursing team. Also, continuous monitoring of quality and performance through surveys
and key performance indicators can positively contribute to better learning and service outcome.

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References:
Bashkin, O., Caspi, S., Haligoa, R., Mizrahi, S., & Stalnikowicz, R. (2015). Organizational
factors affecting length of stay in the emergency department: initial observational
study. Israel journal of health policy research, 4(1), 38.
Chan, T., Bakewell, F., Orlich, D., & Sherbino, J. (2014). Conflict prevention, conflict
mitigation, and manifestations of conflict during emergency department
consultations. Academic Emergency Medicine, 21(3), 308-313.
Ehsani, S. R., Cheraghi, M. A., Nejati, A., Salari, A., Esmaeilpoor, A. H., & Nejad, E. M.
(2013). Medication errors of nurses in the emergency department. Journal of medical
ethics and history of medicine, 6.
Guthrle, A. and Hochman, S. (2019). Risk Management: Falls in the Emergency Department.
[online] Emra.org. Available at: https://www.emra.org/emresident/article/falls-in-the-ed/
[Accessed 14 May 2019].
McErlean, D. R., & Hughes, J. A. (2017). Who falls in an adult emergency department and why
—A retrospective review. Australasian Emergency Nursing Journal, 20(1), 12-16.
Muray, M., Bélanger, C. H., & Razmak, J. (2018). Fall prevention strategy in an emergency
department. International journal of health care quality assurance, 31(1), 2-9.
Saeed, T., Almas, S., Anis-ul-Haq, M., & Niazi, G. S. K. (2014). Leadership styles: relationship
with conflict management styles. International Journal of Conflict Management, 25(3),
214-225.

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Seow, E. (2013). Leading and managing an emergency department—a personal view. Journal of
Acute Medicine, 3(3), 61-66.
Sickbert-Bennett, E. E., DiBiase, L. M., Willis, T. M. S., Wolak, E. S., Weber, D. J., & Rutala,
W. A. (2016). Reduction of healthcare-associated infections by exceeding high
compliance with hand hygiene practices. Emerging infectious diseases, 22(9), 1628.
Appendix:
(Source: Guthrle and Hochman 2019)
MEDFRAT:
MEDFRAT risk assessment tool is also known as the Memorial Emergency Department Fall
Risk assessment tool. The tool is used to assess disorientation/confusion, intoxication or
sedation, altered elimination, impaired gait, use of assistive mobility devices and a history of fall
within the previous 3 months. The scale comprises of three sections, the first part comprises of
fall risk status, the second part contains the risk factor checklist and the third part contains an
action plan in order to prevent falls among the patients.
KINDER1:
The KINDER1 assessment tool was also developed for use within the emergency department.
The tool helps in the rapid identification of the patient’s risk pertaining to falls. The tool
comprises of five assessment points that includes, altered mental status, Intoxication or substance
confusion, impaired mobility, advanced age and admitted to emergency because of falls. On the
basis of the risk score, the patient’s susceptibility to fall is determined.