Case Study: Ethical Violations and Communication Failures in Hospitals

This case study examines a critical ethical breach within a hospital setting, where a patient with Hepatitis C and a knee injury was admitted without proper communication to the healthcare staff, leading to potential risks. The assignment highlights the importance of clear communication, adherence to ethical standards, and the use of tools like the SBAR checklist to ensure patient safety and prevent medical errors. It explores the potential consequences of such breaches, including the spread of infection, erroneous treatments, and legal ramifications. The study emphasizes the need for quality control measures, staff training, and technological integration to improve healthcare services. Furthermore, it underscores the importance of teamwork, professional responsibility, and the protection of patient rights in maintaining a safe and ethical healthcare environment. The case study also discusses the importance of incident reporting, regulatory compliance, and proactive measures to prevent future occurrences, ultimately aiming to enhance the quality of care and patient outcomes.

Running head: CRITICAL INCIDENT ANALYSIS
Name of the student
University name
Author’s note

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Introduction
The implementation of professional ethics at workplace is crucial in maintaining the
quality and standards of the services. The development of the suitable strategies for educating the
employees regarding the importance of professionalism helps in meeting with the objectives of
healthcare services (Powell-Cope et al. 2008). It is advisable that in case of emergency
admission of a patient within the hospital they should undergo thorough test and amalsysis;
before being handed over to concerned doctors or particular health departments. This help in
reducing the chances of errors or risk within a medical set up by maintaining authenticity of the
care approaches and services. In this respect, a patient was suffering from hepatitis C and also
had knee injury was being admitted to the hospital (Holland, 2015).
Here, the fact that the patient was suffering from hepatitis was not communicated to the
nurses and they got the patient admitted to the ICU. The blame was later shifted upon the
reception staff for allowing a patient with hepatitis C into the surgical hall. In this respect, there
was a breach of ethics which places importance upon communication for maintaining
transparency and clarity within the care delivery process (Anand et al. 2004). Therefore, a clear
breach of ethics had take place within the hospital setup and resulted in huge mishap and
consequent disorder within the care setup.
The World Health Organization (WHO) looks up to patient safety as one of the major
responsibilities. The WHO has provided a list of details which needs to be considered in the
context of dealing with critically ill patients. The staff members here have to undergo safety
training which the patients is of prime importance in handling and management of patients. The

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incidents which occurred due to the breach of communication resulted in a series of negative
consequences which have discussed in the section below. It was impossible for the staff
members to ignore such a crucial fact regarding the present health condition of the patient.
Therefore, important steps and measures were required to be implemented here for redressal of
thee same. This required a thorough scan and investigation of the present scenario which would
highlight any loopholes within the care services delivery. As commented, affective collaboration
is needed between the management and the staffs present within the subordinate level for
prevention of the recurrence of any such similar incidents in the future (World Health
Organization, 2017).
Potential consequences
In this respect, the communication gap would have resulted in transmission of the
disease to the attending staff and health care practitioners. As commented by Holland (2015),
hepatitis C is a silent killer and highly contagious; therefore the same has the potential of
subjecting a vast number of people to lethal infection. The same can also endanger the safety of
the hospital as the infection can spread through many channels. The infected staffs when
handling the other admitted patients within the hospital receiving care services for other allied
sicknesses and illnesses can also transmit the infection to them.
Additionally the aseptic environment of the hospital will be fully risked under those
situations as the infected staffs could be handling and managing the important articles and
instruments within the surgical ward. However, as commented by Anand et al. (2004), early
detection of the infection can prevent the spread the contagious disease and also safeguard the
health of the patient. In this respect, the doctors have no prior information about the health of the

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patients resulting in erroneous treatment and medication prescription. The doctors only got to
know about the incident later when the patient was admitted to the operations theatre and much
of the preparations have been met. In this case, had the operation been conducted major health
risks would have been placed risking the recovery and survival of the patient.
Quality control
Even mistakes are often made in hospitals; the main objective is to find out ways through
which quality can be achieved. It is essential that all the staffs in a hospital adopt to the changes
that will enhance the strategy implementation. Maintaining quality is an important aspect of any
organization that wants to grow (Benatar et al, 2011). The main motive is to smoothen the
handling of the patients from the reception table to the final handling.
Mistakes that often occur during handing over of the patients such as patients contracting
infection with secondary diseases must be minimized and mitigated. According to the health
foundation, the main objective of any hospital is to look after the patient’s wellbeing and protect
him/her from any infectious diseases in the vicinity. Security here means protecting the patients
and prevention of the outbreak of diseases (Boylan, 2006). Although health centers are often
seen to be crowded, a prime objective of health care management is to prevent the spread of
diseases to other patients. This objective can be accomplished only if the professional ethics and
the health security are followed. In certain instances, the professional staffs that work in
laboratories are forced to obey the laboratory rules, because they are at the high risk of getting
infected.
Performance appraisals are one way through which several improvements that are
strategized can be determined. Evaluating the staffs regularly to gauge their performance will

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help the hospital authority to improve their services (Butts, 2012). This kind of move is
precalculated so that the hospital can improve their quality of services. Along with the steps
mentioned before, the patients can be interviewed to ascertain that the proper services are
dispensed to them. The patients can be provided with the option of giving views according to
their interest. The records and the tests of the patients and must be examined thoroughly and
before admitting the patient for further treatment (Butts, 2012).
Certain changes can be put in place just to ensure that the projected goal is accomplished.
If strategies are framed well then quality improvement can be achieved. The incorporation of
technology in to the management of work is an inevitable step (Holland, 2015). The advantage of
technology is that it makes the work easy and helps in proper management of data. Instead of
recording patient’s data manually, the digitization of the data will be helpful in sharing the data
with other departments of health. This step will ensure that every piece of information is taken
into account carefully before further treatment of the patient (Lynch et al., 2010).
Moreover, the staffs must be trained so that they can handle and deal with patients
ethically. Although some techniques are not taught in class, they can be effectively provided to
the staffs during workshops which can effectively increase the skills of the staffs. The staffs can
be taken to the soft skills development workshops that will be under the scrutiny of the
regulatory bodies (Benatar et al., 2011). To ensure that the staffs are up to date with the diverse
and newer protocols, regular seminars can be organized. At the same time, the departmental
heads must be directed with managing staffs in the various sectors.
Along with the other soft skills, good communication channels can be created to reduce
the erroes in medical procedures. The bureaucracy must be hindered in the free flow of

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information. Channels can be devised that help in the free flow of information from the lower
levels to the top levels without much hassle (Lynch et al., 2010). Such openness is required so
that the staffs can feel they are valued. Experts can also be involved to work along with the staffs
so they can get better exposures.
Discussion:
The criticality of patient handover requires strict adherence to ethical standards
(McFetridge et al., 2007). Improper articulation of the transition process can lead to errors that
can have heavy and costly implications for both the patient and the responsible nurse. World
Health Organization mandates adherence to the code of conduct stipulated by them (Holland,
2015). A complete set of guidelines stipulating the rules and regulations for the medical
practitioner, should be available with the nurse. In light of the case study, it is evident that he
hospital did not maintain a proper checklist. Additionally, the usage of Situation, Background,
Assessment and Reccomendation (SBAR) checklist is also recommended by the WHO, and
should be used in the patient handover between different sections (WHO, 2007). This can ensure
complete awareness of the receiving nurse about the patient and other relevant information. This
procedure that the relevant healthcare personell have the required information about the patient
who is supposed to be received. In the present scenario, complete information was not provided
by the nurse in the ward to the nurse in the operation theate, which resulted in a mistake done by
the surgeon. This could have proven to be costly to the team assigned to help the patient (Fry et
al., 2010).
This grave condition was owing to a failure by the hospitals, in the adoption of the
international requitement of the usage of the SBAR checklist, that allows the identification of

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the patient and their medical conditions by medical staff (Pope et al., 2008). There was also
reluctance in embracing the protocols, and the safety measures were also ignored, something that
could have been easily implemented to avoid the dangerous consequences (Entwistle, 2011). The
nurse behaviour showed a disparity between better practices and their modus operandi. The lack
of disclosure of patient health information during the handover casn be considered as a complete
failure of the professional duty. Also, a lack of good channel to advance the information caused
a communication breakdown (Bandman et al., 2002). Evidently enough, the patient’s status
remained unclear to the operating team, until it was identified by the leading surgeon. Needless
to say that commun ication is a key element by which staff can share information and provide
support. Blame can also be givcen on the failure to implement systems that facilitate and relay
information, thereby causing the communication breakdown. This proved to be very costly to the
hospital with the realization of how they are lacking in the new technology. Most importantly, an
absence of team work and unity allowed the big human error that could have potentially risked
several people to Hepatitis C infection.
The case above reflects upon a lack of ethical standards in the workplace and a complete
con compliance to ethics. Considering that this occurred in a healthcare centre, that is responsible
for providence and maintenance of well being and health living, and is responsible for saving
lives, it can be well expected from them to have complete and unfaltering adherence to standards
and campaining (Butts et al., 2012). If the incident was reported to the regulatory authorities,
jobs of several nurses and health practitioners could have been at stake (however, the issue went
unreported due to the risk of panic and havoc that might ensue). However, since the source of the
problem was known, it was possible to contain the situation within the lower management, and
prevented the loss of reputation of qualified professional nurses. This therefore also helped to

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prevent defamation of the reputation of the health care center, and preventing the patients
doubting the quality of services provided (Bradley and Burls, 2000). Considering the fact the to
err is human, such risks cannot and should not be ignored.
Additionally, this incident can also be seen as a violation to the human rights of the
patients. Every patient have the basic right to avail proper diagnosis and treatment without being
at risk of being exposed or risking the well being of other patients and healthcare professionals
(Coffey et al., 2010). Denying such rights, and having an awareness of such violation can cause
complications later. Professional requirement dictates being proactive in determining or
identifying the root cause of any health issues faced by the patient in the healthcare centre
(Boylan, 2006). Legal actions can be taken on the healthcare providers due to the non adherence
to such guidelines and failing to appropriately address the problem.
One of the most serious mistakes committed by clinicians is the unfamiliarity with
patients. The highest order of negligence is failure to understand the patient and is greatly
criticized by standards of nursing care. Patient involvement in the medication is the process is a
correct trend, which helps in the correct identification of their problems. In this case the patient
was not involved in the process of diagnosis (Haynes et al. 2009). This a mistake since patients
can describe their symptoms properly.
According to recent research, the health sector is growing at a fast pace. Hospitals
incorporate relevant technology to help in diagnosis and recording of data. Thus, there cannot be
any excuse relating to failure of information transfer from one section to the other. This is
because the process has been made simple, thereby minimizing the risks (Dawson et al. 2007).

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Observation and adherence to healthcare rules and regulations is very vital. This
helps to protect patient health as well as that of the health practitioners in the delivery process.
With increase in modernization, some of these rules are reviewed and changed so as to cope with
the emerging challenges. Changes are easy to make but the core principles need to be the same.
In hospitals, healthcare practice amendments is meant to be a corporate procedure. This will help
to ensure that key patient and healthcare concepts are retained and if possible made stronger
(Carthey 2001).
In order to address the changes, some steps need to be placed into practice.
Carrying out meetings with doctors will help in identifying the problem (Chaharsoughi et al.
2014). These meetings will help to determine the issues faced by the staff, thereby helping in
quality delivery. The staff will be provided an open forum to discuss issues that they face during
their work and enable them to express their issues.
Conclusion
Perfection is the top most priority in the field of medicine. Patients trust their
health practitioners with their life and it should be considered sacred. Mistakes resulting from
negligence and inability to follow rules and regulations put forth by the organizations like the
World Health Organization (WHO) needs to be avoided. The medical staff like nurses should
have proper training and should be subjected to good medical practices, which will help them to
carry out their duties in an efficient manner. It is necessary to carry out performance checks of
the medical employees, since its failure can lead to serious consequences. Such failures not only
affects patient health but also affects the reputation of the medical organization. Simple mistakes
that occur at the time of patient admission if overlooked can give rise to huge losses, which

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cannot be avoided. With the introduction of various changes in the field of medicine, it is
necessary for the organization to update its employees about the changes so that they can
implement it in their line of profession. Further research is needed to determine the level of
awareness regarding standards of quality in hospitals and among the hospital staff or employees.
Thus it can be inferred that the hospital management did not take into
consideration the practices that are far better and which are normally followed by healthcare
facilities. The healthcare officials were not interested in adapting to the international standards
that control the various healthcare sectors around the World. This in turn caused a serious
mistake that can be subjected to punishable offence by the law. Health facilities should be
properly guided and financed by relevant organizational bodies.

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