Quality Management in Health: Analyzing Errors and Safety Culture

This report delves into the critical aspects of quality management in healthcare, using a case study to analyze medical errors and patient safety concerns. It examines various types of errors, including medication mistakes, incomplete prescriptions, and chart mismanagement, highlighting their causes, contributing factors, and frequency. The report emphasizes the importance of a strong safety culture within hospitals and explores the application of the Manchester Patient Safety Framework to assess and improve healthcare practices. It provides actionable preventive measures, such as staff training, electronic record systems, and clear communication protocols, to mitigate errors. Furthermore, the report outlines the actions a healthcare executive, Carol Jones, should take to address the identified issues, including delegation, stakeholder engagement, and patient-centered care strategies. The analysis underscores the need for continuous improvement, teamwork, and a commitment to patient safety within healthcare organizations. The study uses multiple sources to back up the analysis and recommendations.

Running head: QUALITY MANAGEMENT IN HEALTH 1
Quality Management in Health
Student’s Name
Institutional Affiliation

QUALITY MANAGEMENT IN HEALTH 2
Quality and Safety issues
The family reports of errors in the medication of the father. The nurses at the health
facility are responsible for the mistakes. The father of the advocate gets two bugs related to the
hospital. Additionally, the carelessness by the nurses makes the father develop chest infractions.
The physicians at the emergency wards fail to prescribe the dosage to the father. Other doctors
write an incomplete prescription to the elderly patient. The doctors fail to write all the conditions
of the patient on the charts. Nurses at times do not read the treatment charts appropriately. Vital
care information is missing from the charts. Nurses cannot understand the doctor's instruction on
how to handle patients. Some nurses only look at the first page of the charts but fail to study the
proceeding pages as well.
Occasionally, the nurses failed to handover the chart in good time. At times, nurses go
home without administering the drugs to the patient. Nurses fail to read the drug container
appropriately. Therefore they can give wrong medicine to the patient. Nurses misplace the charts
of patients. Thus, the following nurse cannot find the lost table. The nurses are disorganized and
spend a lot of time in retrieving a missing chart. In various occasions, the medical staff mixes up
the medications, therefore, confusing the patient and the wife. The management of the hospital
has assured the daughter of the elderly patient that changes are imminent to correct the errors.
Unfortunately, the nurses and the doctors keep on repeating the mistakes.
The doctors at the facility lack medical records of the patients. Additionally, the
physicians do not interrogate the patients about their records. The doctors fail to tell the type of
medications that the incoming patients are on. The patients do not know the identity of the
dosage that they receive from the hospital. Doctors at times fail to offer medication printouts to
the patients.

QUALITY MANAGEMENT IN HEALTH 3
Causes of the medical errors
The hospital management should share the blame on the mistakes. The administration has
not been strict on the nursing staff. Nurses’ carelessness leads to the clinical errors. The doctors
are the other victims as they fail to write down all the medications (Norman et al., 2017). The
doctors at times fail to write down the medication. Thus the patient fails to take medicine in the
right dosage. The nurses carelessly handle the patient's chart hence misplacing them. The
clinicians cannot read the prescriptions. At times, the nurses cannot understand the bottles that
contain the drugs (Ryan et al., 2014). The medical administration promises to rectify the errors
but fail to do so. The doctors fail to print out the medical records of the patients. Nurses take
more extended hours to recover a misplaced chart. Doctors write unclear prescription notes.
Thus, the nurses cannot read them to the patients.
Contributing factors
The nurses are making the countless mistakes when handling the elderly patient because
they fear her advocate daughter. The hospital lacks electronic system hence cannot keep
electronic records. There is no nurse to move about with a trolley to give out medication to the
patients (Patel, & Bergl, 2017). Nurses lack regular training on the issuance of drugs. The
doctors do not write clear prescription statements. The nurses are careless with patient's charts.
Moreover, the management is not strict enough and do not closely supervise the staff members.
The frequency of the occurrences
The errors generally occur almost on a daily basis. The prescription of drugs is a daily
affair hence improper order happens daily (Chawla, Goswami, Tayal, & Mallika, 2015). The
mother of the advocate visits the husband daily to prevent the human errors. Moreover, the errors
are numerous and affect almost all patients in the hospital.

QUALITY MANAGEMENT IN HEALTH 4
Preventive actions
The hospital administration should provide regular training to the nurses to sharpen their
medication skills. In training, the trainers should remind the nurses to avoid the errors in
prescription. Nurses need specialized training to enable them correctly read the containers of
medication (Goldsworthy, & Waters, 2017). The clinicians should go through the entire patient's
chart instead of looking at the first paper only. Nurses should safely store the charts without
misplacing them. Moreover, the doctors should write clear prescriptions of the drugs.
Furthermore, the nurses should seek clarifications from the doctor if they don't understand a
given medical note. The hospital should use electronic means to process the prescription for
patients (McKean, 2016). Additionally, nurses should read all the prescription information
without omitting any details. The hospital executive should regularly supervise the nurses’
activities. Moreover, a nurse should be mandated to go around the ward to give medications to
the patients.
Analysis of safety culture in hospitals
The case scenario
Any health facility should enact a safety culture to the employees to enable the nurses to
offer quality services to the patients. The senior management delegates follow-up team to the
wards. The functions of the unit are to oversee the duties of nurses in caring for the admitted
patients (Marshall et al., 2017). Moreover, the group ensures that diagnosis and treatment are
error-free (Thomas, Ashcroft, Parker, & Phipps, 2015). The family members of the patient do not
understand the procedures at the hospital. Besides, the relatives of the elderly patients have high
expectations about the hospital. The expectations follow the critical situation of the patient.

QUALITY MANAGEMENT IN HEALTH 5
The patient is suffering from multiple ailments and should obtain high-quality care. The
hospital has an insufficient number of nurses. Moreover, there is an increase in the number of
patients visiting the health facility. The staff at the ward does not know about the issues that the
family is talking about previously. The team believes that the wife is always present and
contributes to the decision making about the care of the husband. Other nurses have
acknowledged the mistakes that the family raised and are determined to find the route course and
eventually solve the problems
The analysis using Manchester Patient Safety Framework
The framework is for medical practitioners who want to prepare a training session to
learn more about the how to treat patients in the health facility safely. The safety tool applies to
both the nursing groups and the hospital as a whole (Sari, 2017). The healthcare tool is a source
of valuable information for safety care. Moreover, the tool assists in the formation and continuity
of safe treatment in health facilities (Parker, Wensing, Esmail, & Valderas, 2015). Health
practitioners can gauge their understanding of safe therapy and how to implement the culture into
practice. The Manchester tool enables the nurses to learn more about offering secure medical
attention. The Manchester Patient Safety Framework (TMSF) is applicable in almost all fields of
medicine (Lainer, Vögele, Wensing, & Sönnichsen, 2015). Nurses use the Safety tool to check
on their developmental safety capacity.
The hospital should emphasize the need for all employees to commit to constant safety
improvement. The family members led by the advocate have raised a lot of issues concerning the
quality of care in the hospital. Instead of complaining about the understaffing and the increase in
the number of patients, the nurses should strive to improve the quality of healthcare. The hospital
should prioritize the safety of the patients (Bell et al., 2016). The nurse should not fear the

QUALITY MANAGEMENT IN HEALTH 6
inspection by the advocate; instead, they should ensure that the father of the lawyer receives
quality care. The nurses should keep a record of complaints of the patients. Some of the hospital
staff complains that they are unaware of the claims by the family. The allegations show poor
record keeping by the hospital staff.
After taking records, the nurses should evaluate them. Moreover, they should look at the
possible solutions to the errors that the family reported. The nurses should learn from the
mistakes that the family of the patient is accusing them of doing to the patient. They should look
at practical ways of avoiding the previous errors. Nurses form teams with effective
communication strategies (Bell et al., 2016). The hospital should accept complaints from patients
and act upon them with accuracy. The management should closely supervise the activities of the
nurses. The safety tool emphasizes the need to train and educate the nurses regularly. The
training should focus on the need to avoid errors in the provision of healthcare (Parker, Wensing,
Esmail, & Valderas, 2015). Additionally, nurses should ensure that they administer treatment
with undivided attention.
The health organization should emphasize the need for teamwork in healthcare provision.
When working as a team, an individual can identify the mistake by the other and rectify it. The
TMSF requires the health facility to understand the fact that health care safety is complicated and
requires the cooperation of all stakeholders. Therefore, nurses should not work in solitude as they
are prone to errors when working alone. The government, the health organizations, and the
health practitioners should join hands to ensure safety healthcare towards the patient (Parker,
Wensing, Esmail, & Valderas, 2015). From time to time, the health organization should look on
the safety of the patients. The health facility should discover their strong points in the provision
of safe care. The organization should put much effort to improve the safety of the patients. The

QUALITY MANAGEMENT IN HEALTH 7
hospital should identify their weakness and come up with strategies to improve. The diverse
nursing groups should share their opinions to come to a consensus. The nurses should research
on the outlook for a health facility with a culture of safety that is functional (Parker, Wensing,
Esmail, & Valderas, 2015). The teams of nurses should come up with ways of improving the
culture of healthcare provision.
Actions that Carol Jones should take
Carol Jones should instruct senior managers at the hospital to delegate follow-up duties.
The follow-up process should target all the department and wards (Ginter, 2018). The team that
examines the patient after treatment should report their findings to the Chie Executive Officer
(CEO). A small follow-up process is not enough. The CEO should identify the weakness and the
strengths of the process (Prince, Comas-Herrera, Knapp, Guerchet, & Karagiannidou, 2016).
Carol should invest in methods of improving on the weaknesses while upholding the strengths.
Carol should manage the expectations of the patient’s family. She should instruct the heads of
the wards to explain to the family about the treatment procedures.
The family should understand that the hospital is facing a scarcity in the number of
nurses. The patient’s family should also recognize the increase in the number of patients that the
nurses attend to on a daily basis. Carol Jones should use her influential position to hire more
nurses. Additionally, she should seek government’s backing to expand the hospital’s premises
(Secanell et al., 2014). Moreover, Carol should find stakeholder backing to bring more health
facilities into the wards and the health departments. Carol should encourage patients to register
any complaints. The ward staff is claiming that they are not aware of the allegations by the
family.

QUALITY MANAGEMENT IN HEALTH 8
Carol Jones should encourage the nurses to change treatment for a patient only after
consulting the patient and the family members. The patient should contribute to whether the
medication needs alteration or otherwise (Bloom, Propper, Seiler, & Van Reenen, 2015).
Additionally, the relatives should help the patients in making an informed decision. Whenever
the nurse feels that the changes benefit the conditions of the patient, that nurse should inform the
patient about the changes. The doctors should tell the patient about their reasons for changing the
medication (Wager, Lee, & Glaser, 2017). The changes in medicine have caused deaths in the
past so nurses should do it carefully.
Carol should motivate her staff members. Additionally, she should encourage them to
attend to patients with more vigor and interest. She should tell the nurses to be keen in healthcare
provision to avoid errors in their practice. The CEO should encourage the clinicians and
physicians to pay keen attention to the elderly patients. Those individuals who are suffering from
many infections should obtain maximum care (Wager, Lee, & Glaser, 2017). Carol should
encourage the doctors to write down all the medications. Moreover, the physicians should
elaborate the medicines to the understanding of the patients and the nurses. When the doctors are
writing medication, Carol should encourage them to jot down a simple script.
Carol should encourage nurses to observe all the patient's medications. Skipping of a
dosage renders it useless. The CEO should help the doctors to prepare complete charts for the
patients. The physicians should pay attention to the patients having more than one ailment. Each
complication must be on the table no matter the level of seriousness. The doctors should write
notes that the nurses can read (Wager, Lee, & Glaser, 2017). If the nurse cannot understand the
doctor's note, they should go back to the physician and seek clarifications. Nurses should never

QUALITY MANAGEMENT IN HEALTH 9
assume any unclear medication; instead, they should consult with colleagues to get a
clarification.
Carol Jones should organize a special training session to enlighten nurses on reading the
diseases charts. Nurses should consult with colleagues in case of the information in the charts is
not bright enough. Nurses should shift their concentration from the first page of the medication
sheet to view all the leaves. When going home, Carol should encourage the nurses to hand over
their duties to the next nurse. When the nurses are finishing their shifts, they should give
medications to the patients (Wager, Lee, & Glaser, 2017). Besides the charts and the doctor’s
prescriptions, Carol should offer training on the reading of medication bottles. She should ensure
that the containers are well labeled.
Carol should encourage the family of the patients who have a complaint to consult with
the directors of the health departments. The heads of department should respond to the
allegations and ensure that the patient's issues receive maximum attention. If the relatives are not
convinced by the efforts by the departmental heads, they should be free to see the CEO in
person. Carol should encourage the nurses to discharge their duties without fear of the position of
the patient or the relatives in the society. Carol should use the hospital's resources to acquire the
electronics records machine. The instrument assists the hospital to monitor the activities in the
hospital (Powers et al., 2015). Therefore, the executive members can chip in to prevent clinical
errors. Carol should employ a medication nurse to go around with a trolley when issuing
medications to patients in different wards.
The-Plan-Do-Check-Act Cycle (PDCA)
The Cycle encompasses four steps. [Planning, Doing, Checking and Acting] (Lee, Lei, &
Cheng, 2014). The plan is circular meaning that it does not have a destination. The hospital

QUALITY MANAGEMENT IN HEALTH 10
should repeat the steps more often until they find the solutions to their problems. Numerous
problems are facing the health facility. The hospital can use the PDCA to solve the failure of
nurses to read and understand the medication bottle labels.
The Plan
The family advocate highlighted the fact that some nurses cannot understand the labeling
of the medications. The inability of the nurses to correctly read the labels leads to dosage errors.
The errors can pose a severe complication to the patient. Additionally, the misreading can
increase the level of the patient's sickness. On extreme cases, the administration of the wrong
medication to a patient can result in a coma and eventually death (Lim et al., 2015). The hospital
must come up with a well-thought-out plan to enable nurses to read the bottle labels of medicines
correctly.
The hospital management should invest in training nurses on how to understand the
labels and avoid the wrong dosage. When the training is a success, the nurses should be accurate
and prevent the issuance of the wrong dosage. The training should not cost the hospital a lot of
money. Instead, the hospital needs a little amount of investment to carry out the training that
takes one to two weeks. Preparation is the best option for preventing errors in medication (Saier,
2017). The management has the other opportunity of closely supervising the nurses to ensure that
they read the labels correctly. However, close supervision intimidates nurses and leads them into
more mistakes. Therefore, the best way forward is through exposure and training. The hospital
needs to seek moral and financial assistance in carrying out the operation. Moreover, the
government should assist in training nurses.
Do

QUALITY MANAGEMENT IN HEALTH 11
The do part is the action part. Here, health facility rotationally trains nurses. All nurses
cannot gain training at the same time. The hospital can employ more nurses or call nursing
interns to cover up for the nurses during training. The practice should run for a period spanning
one to two weeks. The trainers should urge nurses to be keen when reading the labels. A point of
note is that nurses are literate healthcare professionals (Chen, Mei, Jiang, & Du, 2016). Their
busy schedule limits the time that they spend in understanding the labels. In case the nurse does
not recognize a particular tag, consultation is necessary for colleagues to understand medication.
The hospital should employ more nurses to lift the pressure on the already present nurses
(Larsson, Shima, & Kurisu, 2016). When nurses are working in a pressure-free environment,
they get ample time to understand medication. Consequently, they cannot administer wrong
treatment.
Checking and Action
The hospital should check the outcome of the nurses' training. Proper training enables nurses to
improve their medication skills. The hospital can check the progress by examining the number of
complaints by the patients and their family members. A reduction in the number of complaints
signals the success of the training (Kanai, 2015). The hospital can collect data from the patients
on the frequency of errors in medication. The hospital can design questionnaires and also
conduct interviews with the patients. Correct medications translate into improved healthcare. In
case most patients are approving of the services of the hospital, the indication is that the training
was a success. On the other hand, a lot of dissenting voices indicate the training did not correct
the occurrences of wrong medications. A reduction in the fatality rates indicates the success of
the nurses' training. After the checking, the facility should carry out a regular practice if the
operation is successful. Additionally, the training should be continuous to eliminate clinical

QUALITY MANAGEMENT IN HEALTH 12
errors in medical attention. In case, of complaints from the patients despite the training efforts,
the health facility should look at alternative means of reducing human clinical errors.