Table of Contents
Martin Bromiley as a result of the personal experiences where he had lost his wife has founded the Clinical Human Factors Group during 2007. This particular group has assisted the experts, clinicians as well as some of the enthusiasts in making them understand the human factors at the heart to improve patient safety. Since the person had lost his wife at very younger having two children, Martin Bromiley wanted changes in the healthcare practices with the help of which both the technical innovation and the patient’s improvement can be well encouraged. The case study highlights that Elaine Bromiley was a 37 years old mother which have attended the hospital for elective sinus surgery (Algoso, 2016).
The incident highlights that after the routine anesthetic induction, airway management has been incorporated. The oxygenation of Mr. Bromiley has got deteriorated. The intubation has been started, however, the nurses have not proved to be successful enough in doing this and they, unfortunately, lost her. This paper will discuss in detail the patient safety as per the Australian health care setting. Besides this, the importance of patient safety along with its importance will be reflected. Also, the responsible human factors which are ultimately responsible for ensuring patient safety will be discussed (Bryson, 2016).
The primary reason behind this is that the nurses finding it difficult to follow Airway Society guidelines. It has been observed from the video that high time has been invested by the nurses in intubating the trachea apart from concentrating on ensuring adequate oxygen amount through other means. A breakdown has been observed in the context of the decision making and also the existence of the communication among the consultants has also been rise up (De Simone, 2018). There had existed also a lack of clear leadership style and at the same time the lack of situational analysis along with the assertiveness which comes of the effective and important reasons behind the fatal condition of the patient as per the case study. In this case study, acuity can be explained as one of the intensity measurements in the context of the nursing care which is required by the patient (Burke, 2016). Here an acute-related staffing system helps in controlling the nurse numbers and provide them shift duties as per the needs of the patients and not as per the numbers of the raw patients.
The Australian approach towards patient safety is important since through this, the systemic risks among the patients can get easily detected, and this way the outcomes among the patient can get improved through the clinical based effective risk management responses. The patient safety approach also turned out to be important in this context to check the presence of communication among the team members between the senior management and the registered nurses so that the care or the patient cannot get denied (Della Ratta, 2016).
As a registered nurse, it will be always her responsibility to start with the plan of using the laryngeal mask and listening skills also need to boost encouragement among the medical members and the registered nurses. Now coming to the patient’s safety, patient safety can be defined as one of the healthcare disciplines which got evolved through the complexities in the healthcare systems. Hence through this according to the case study, it will be realized through patient safety, equitable, integrated and along with that the efficient health services can get well managed easily. According to Australian guidelines, the application of safe care procedures along with the use of safe injections should be followed (Deasey, 2016).
In this respect, high acuity levels assist the nurse managers in setting up of the staffing levels in a proper manner through provisioning of long term care along with other treatment and rehabilitation settings. The case study highlights the condition of the high acuity patients who should undergo frequent observations to ensure that they can be able to improve in their life and also can be stable in the future. Prioritizing the patients based on the medical emergencies helps the nurse managers in using a variety of the different scales and the strategies so that the health needs of the patients can be accessed (Deasey, 2016).
In the context of implementing human factors in health care, the root cause analysis highlights two primary themes of the human factors that needed to be considered that are the development of the positive safety culture and at the same time embedding the human factors training within the healthcare. There exist certain elements of the safety culture like open culture, reporting culture, informed culture, learning culture (Dunn Lopez, 2017).
The existence of both planned and structured patient safety workarounds assist the healthcare leaders in undertaking the communication with the frontline healthcare executives which is considered as one of the visible sign off the leader’s commitment so that the patient’s safety can be improved. As per the DAS guidelines, how the patient can be treated with adequate support and panning will get reflected as follows like,
The above guidelines state the fact that in the operating room if the nurses could follow certain plans in an effective way, the patient might get recovered. Now coming to Tabbner’s nursing care, managing the high acuity setting has been described as the four-stage nursing process setting which should not be confused with certain nursing theories along with health informatics (Burke, 2016).
The use of the clinical judgment to maintain the balance between the personal interpretations and the research evidence where critical thinking plays a positive part in categorizing the issue of the clients as well as the course of action. Mind map along with the abductive reasoning should be incorporated as one of the potential alternative strategies so that organized healthcare can be uplifted for the experienced nurses (Swiger, 2016).
Some of the important human factors which are responsible for the patient’s safety at the time of the emergency condition are communication, teamwork along with situational awareness. In the case study, lack of communication has been found between the team members at the time of performing the surgery and many of the team members are not vocalized enough to check that what is happening surrounding them. The team had started with the laryngeal mask. However, when it has been failed, only one alternative was left that is tracheal intubation (Stimpfel, 2020). From this, it can be learned that at the time of undertaking any serious operations, there needs to be a clear plan where vocalizing is also essential. Talk through the plan with the team before the starting of the procedures will help the individuals in knowing that what will be happening in the next few hours.
In addition to this, the role of the human factors also involves listening to the team members and also to follow certain patterns at the time of approaching the critical issue with the doctors. At the time of undergoing the critical surgery, the team needs to undertake the controlling authority and at the same time should keep an overview regarding the entire situation and accordingly planning for the alternative plans (Della Ratta, 2016). It is always the responsibility of the healthcare team, especially the nurse to act as the primary contact point between the surgical team and the other departments where it should ensure that the important information needs to be well communicated with certain effectiveness and clarity (Eriksson, 2018).
According to WHO’s response to the safety of the patients, patient safety can be well promoted through the enhancement of the public awareness as well as engagement so that proper working, as well as understanding, could be established towards the conformity of the global solidarity and action. The factors that need to be undertaken by the registered nurse at the time of dealing with the emergency are situational awareness, teamwork, and communication (Burke, 2016). Team Situation Awareness can be defined as one of the critical factors towards the effectiveness of the Operating Room which can create a positive impact on the safety and the quality care of the patient. The team situation awareness can be defined as a situation, where the team is having a common goal as well as the functions where the role of the different team members is interdependent to each other. According to Della Ratta (2016,p.3046), each team member is having their situation awareness especially among the registered nurse were the contributing aspects are as follow:
One of the important sides of the situation awareness is orientation, evaluation, action, and access where the processing of the information at the right time and also to the right people needs to be characterized and evaluated so that the reliability, as well as the performances of the registered nurses and also among the healthcare team members, can get uplifted (Twigg, 2019).
The key points for all the factors like the situation awareness, communication, and the teamwork should make incorporation of the first line leadership where supervision along with the effectiveness of the standard policies, administrative controls should be present behind the delivery of the optimum healthcare facilities (Wolf, 2017). The operator interface design needs to be more associate and should provide a comprehensive as well as centered application set which will help in accessing the knowledge so that the abnormal situations can be easily dealt (Eriksson, 2018).
Side by side, to deliver optimum healthcare, a set of the comprehensive set of competencies along with the maintenance of the situation management should be present in a continual manner based on which the operational performances over time can get improved. The key elements of the awareness team situation are the common mental model development, initiation of the team-based strategies along with the troubleshooting, and problem-solving (Della Ratta, 2016).
With the help of these elements, the roles and responsibilities of the team get defined clearly through which the valuable teamwork can get emphasized along with the development of the team-based training exercises like the periodical reviews of the procedures associated with the human reliability and the collaborations. Through these factors, certain aspects get highlighted like the patient safety culture measurement “Within health service organizations, intelligence about emerging safety and quality issues is gathered by frontline staff during the normal course of their everyday work. These clinicians, administrators, managers, and auxiliary staff are the closest observers of concerning patterns, and of workplace conditions which allow these patterns to emerge and persist (Ryan, 2016).”
To conclude, the key points that have been reflected in the entire task is that there need to be clear patient safety goals through which the optimum health condition can be attained. Along with this, the factors like communication, situation awareness as well as teamwork is highly needed so that better care and the nursing practices can be delivered to receive a better outcome.
It can also be stated that the Commission works with the Australian government, state, and territories along with the clinicians and the patients to deliver safer and quality improvement to mitigate the risks and at the same time improving the patient outcomes through the clinical risk management processes. It can be stated that the development of the National Patient Safety Learning model is important through which the better services can be delivered which will complement support, adequate guidance’s as per the Australian Health laws, and the schemes.
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