NURSING 5: Analysis of Bundaberg Hospital Failure and Governance

This report examines the Bundaberg Hospital failure, a significant case of healthcare system breakdown, focusing on clinical governance and organizational culture. The analysis highlights the influence of leadership and culture, particularly the lack of a robust safety culture, which led to surgical errors and adverse patient events. The report discusses how the hospital's leadership failed to address safety issues and promote incident reporting, as well as the importance of risk management systems in preventing errors. Furthermore, it explores the impact of the hospital's culture of economic rationalism and concealment, which fostered communication gaps and incivility among staff, contributing to poor patient safety standards. The report emphasizes the need for a just culture that encourages incident reporting and learning from mistakes, thereby improving patient safety and healthcare outcomes. The findings underscore the importance of strong leadership, effective risk management, and a positive organizational culture in preventing similar failures in healthcare settings.

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Any failure in health care system is a critical issue that leads to many public inquiries.
One such famous public inquiry is the Bundaberg public inquiry which investigated about the
events of clinical incidents, surgical errors and multiple adequacies at Bundaberg hospital.
This incident is a famous example of Australian health system failure. This papers aims to
review the Bundaberg hospital failure based on the module content related to clinical
governance and organizational culture.
Clinical governance part:
The revised clinical governance framework consists of five domains such as leadership
and culture, workforce, risk management, clinical practice and consumer partnership. The
system failure in the Bundaberg hospital might have been influenced by the domain of
leadership and culture and risk management. The Bundaberg hospital system failure has been
linked to leadership and culture because the hospital was found to have a faulty safety culture
resulting in many surgical errors and adverse events for patient (Davies, 2005).
For example, as per the explanation of Dr. Thiele in the Bundaberg inquiry, he reported
being frustrated with the culture at the hospital as there were decline in safety standards,
inefficiency in surgical scheduling and loss of registrars. The hospital culture focused on
economic rationalism rather than patient care and safety (Davies, 2005). Organizational
culture is informed by nature of its leadership (Muls et al., 2015) and in the context of
Bundaberg inquiry, poor safety culture was seen because of lack of appropriate leadership
and culture to support high standard and quality of care at Bundaberg hospital. The
leadership of the hospital was not active enough to address safety issues and encourage
reporting about adverse events too. Joint Commission (2017) explains that in any health care

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organization, the first priority of all leaders should be to be accountable for effective care and
adapt all measures to promote safety of patients. This involves playing active role to improve
safety and organizational culture and address systematic flaws in the organization. However,
leadership role was completely missing in the Bundaberg hospital. Terzioglu, Temel and
Uslu Sahan (2016) also recommend having robust institutional culture to promote justice
both for patients as well as staffs.
In any hospital, risk management is crucial to minimize harm that can occur due to faulty
clinical systems or practices in a hospital. It involves the systematic identification,
assessment and evaluation of risk. However, the Bundaberg clinical system failure occurred
as it had poor system to manage risk or any system to report about surgical errors or patient
safety risk. The hospital was instead accused for inappropriate reporting of deaths and there
were many cases of incomplete incident report. Hence, if the hospital has adequate risk
management plan, they would have documented any patient safety event in incident report
and dealt with it through formal channels (Davies, 2005). However, any such activity was
seriously missing at the hospital. Rafter et al. (2014) explains adverse event can occur in any
setting. However, the crucial thing is that the organizational leadership must focus on
learning from those adverse events and not repeating them. Unless there is systematic method
to identify and evaluate adverse events, progress in patient safety cannot occur. The same
case was found for the Bundaberg hospital failure case too. Hence, to ensure that such errors
do occur again, it is necessary that clinical managers in the hospital establish a system for
risk management and controlling adverse events. Howell et al. (2017) recommends that
incident reporting system in hospitals should be introduced as it not only helps in the

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identification of device failures and medication errors. Instead, it also supports identification
of training and resource needs in hospitals.
Organizational culture:
Whistle blower is a term used to define a person involved in reporting about persons or
organizations involved in an unlawful and moral act according to desired standards present in
current times (Doran, 2016).
In the Bundaberg inquiry, it was found that the organization culture significantly
contributed to poor quality of care. For example, the Bundaberg hospital had a culture of
economic rationalism that lead to poor decisions about care. Instead of taking systematic steps to
identify areas of discrepancies or factors that contributes to adverse event, the hospital had a
culture of concealment of practices so that they it prevents them any embarrassment when the
same is identified by the Queensland Health. The hospital staffs experienced bullying and
frustration too as many overseas trained doctors where recruited in the hospital. However, there
was no system to coordinate induction or integration of overseas staffs thus resulting in language
and communication gaps (Davies, 2005). Hence, negative patient safety event dominated at the
hospitals. Davidson et al. (2017) shows that communication gap is a major factor that increases
the likelihood of surgical errors and other patient safety risk. Kaiser (2017) explains that
organizational culture and leadership strongly influence behaviour of health care professionals
and poor response to socialization among health care staffs lead to incivility in staffs. Hence,
inappropriate organizational culture becomes a factor for incivility among staffs, poor standards
of care and no improvement in patient safety standards.

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The Bundaberg hospital has a culture of concealment and this further promoted hiding or
disclosing failure to relevant health care authorities. This can be said because in the inquiry, it
was found that the hospital administrators ignored or suppressed criticism and any inappropriate
service or practices was often concealing by not reporting about it (Davies, 2005). Research
studies clearly show the link between organizational culture and it impact on hiding or disclosing
vital information related to patient safety. For example, Hemphill (2015, June) gives the
evidence regarding preference for concealment or avoiding disclosure of failures because of poor
safety cultures. Unless a safety culture is present at any hospital, the management staffs will give
no value to reporting of errors, patient risk and near missed cases. The same was seen at the
Bundaberg hospital too because of lack of safety culture. Alomari et al. (2018) supported too
regarding the positive effects of a just culture environment on prevent medication errors and the
negative impact of a blaming culture on repetition of risk. The culture of the Bundaberg hospital
was such that it strongly promoted blame culture. Culture of blame was also identified as one of
the barriers in reporting clinical incidents according to the Queensland Health Review team. This
shows the need for the hospital to move from blame culture to a just culture (Davies, 2005). This
is critical because every health care professionals have equal role in ensuring quality and safety
in a health care setting. Hence, instead of using blame culture to avoid incident reporting, it is
necessary to engage in orientation so that staffs avoid fearing about punitive actions and
understand the positive effect of incident reporting in the future (Dekker & Breakey, 2016).

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