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Health Care Mgmt. BHA 3002- Unit VI Essay

Health Care Mgmt. BHA 3002- Unit VI Essay

The local university hospital is a 600 bed facility and it has been reported that the level of operating room deaths involving surgeries has increased. As a result of these incidents it has damaged the reputation of the hospital. The reason that the increase has happened is because the amount of anesthesia that is given to each patient prior to surgery is a higher dose than what is recommended for the weight of each patient. This is because the anesthesiologist is the only one available for the entire hospital and is highly dependent upon by the other staff. The human resources department had indicated that the contributing factor in the operating room deaths is due to the surgical residents performing 2-3 surgeries back to back after working a 24 hour shift and not ensuring the right dosage for each patient.

The university hospital is a teaching facility along with the Emory University College. Some years ago the hospital expanded from having 400 to 600 beds. The surgeries that were performed included but were not limited to open heart surgery. Every operation that required anesthesia were performed in the operating room. Any other surgical procedures were done in other departments such as the emergency room.

Identifying the Crisis

Hundreds of patients have died after being over anesthetized prior to surgery causing them not to awake after surgery or may they have increased heart rate in which they die right after they come out of surgery. Administering too much of anything can happen at any time and anywhere. Consequently, the increased number of deaths due to being over anesthetized is a result of staff working too long of a shift and doing too many surgical procedures back to back.

Crisis Management Triad

Preventive Phase

Internal crisis can be prevented with policies and procedures put in place to ensure both patient and staff safety. To prevent errors, implementing checklists has proven to be effective in all clinical procedures. Training and reinforcement of specific patient safety protocols must be ongoing. Also, there needs to be a zero tolerance policy in place to prevent the smallest infractions from happening and taken seriously if they do happen. When small infractions go without consequences, the gray areas of acceptable rule breaking becomes wider and wider until there are hardly any rules with consequences left. Another preventive measure would be to provide documents of medical material that state the significance of reducing shift prospective. Over emphasize the importance of taking a break when needed for any of the staff including the surgical residents. If the staff member has previously worked a full shift that day, then another resident needs to be called to go in and take over for the other person to ensure that the staff is not over-worked.

Concurrent Phase

Notify the patients of the potential risks that the procedure that they are having will have. Before surgery, the residents will inform the patients of any types of complications, such as diseases, bleeding (if any) and any side effects that might follow the surgery. After surgery, symptoms may occur that the patient may have never experienced before. Encourage the patient to have people of importance around them after the surgery for as long as a week to make sure that nothing goes wrong with the patient.

Recovery Phase

Prior to the patient being discharged, the human resources department and hospital personnel will ensure the performance of the surgical residents once the patient has gotten the proper amount of rest to decide the favorable outcome of having the resident relieved by an on call relief resident. Try to determine if shortening the hours and having a relief resident is effective in any way.

Creating a Plan

I would inform my staff that if the triad phase wasn’t put into action, then there would be great danger for the facility. Putting policies and procedures into place and strictly enforcing them would save patients’ lives. I would post the policies and procedures all around the hospital and not just in one place. This is to ensure that the staff will not go against what is being enforced. Although there is really no way to be everywhere at one time, you would like to think that the entire staff is following the rules of the facility as directed.


Safian, S.

Fundamentals of health care administration

(1st ed.).

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