Organizational Systems & Quality Leadership

During the process of health care, accidents that occur are attributed to specific levels of failure. Basically, there are four levels of failure in health care: unsafe supervision, organizational influences, unsafe acts and the conditions that occur before the unsafe acts. These failures result from individual weaknesses and barriers that hinder individuals from taking action. When many individual failures accumulate in an organization, the whole system is likely to fail. The scenario of Mr. B was associated with such failures as the administration of wrong drugs by the nurse J. In addition to these failures, the ED physician had evaluated Mr. B as having elevated cholesterol and lipids while the admitting nurse admitted Mr. B. of impaired glucose tolerance and prostate cancer. The medication that the ED physician were meant to suppress the back pain that Mr. B was experience and therefore they could not provide a good solution for the patient, thus led to his death.

Change theory

The change theory uses organizational development in order to achieve the desired results. Organizational development uses planned and well organized efforts that are meant to improve the viability and effectiveness of the health care organizations. According to (Wendell & Bell (2003) “organizational development is a response to change, a complex educational strategy intended to change the beliefs, attitudes, values, and structure of organization so that they can better adapt to new technologies, marketing and challenges, and the dizzying rate of change itself”. Therefore organization development is meant to establish processes that are designed for the purposes of bringing specific results. In order to achieve such results, organization development can incorporate interventions by the use of behavioral-science knowledge, planning, system improvement, self analysis and organization reflection (Wendell & Bell, 2003). These interventions are expected to improve renewal processes and problem solving skills in an organization (Wendell & Cecil, 2003). This is achieved through a collaborative and an effective management organization. The current scenario of the rural hospital where Mr. B was admitted can be improved through organizational development. It is important for the management of the rural hospital to carry out an institutional assessment. This assessment is important in that it would assist in determining the kind of institutional change that is needed so as to improve the service delivery and reduce the chances of patients dying due to minor errors (Stranks, 2007). For instance, the hospital can train the nurses on how to handle patients during critical situations like that of Mr. B. In addition, the physician in the emergency department was not able to serve the three patients at one moment since there were some of the patients who required more attention, this can be improved by the addition of more health care staff.

Failure mode and effects analysis

FMEA is a procedure that is used to make an analysis of the possible failures in an organization. A well organized FMEA procedure can assist an organization to note the likely modes of failure based on the historical background when using similar services, this can help an organization to eliminate such failures from the system with less expenditure and efforts thereby cutting down the cost of service delivery (Cilliers, 1998). When using FMEA, failures that have serious consequences are given more priority. A FMEA is supposed to provide current actions and information of a risk so that they can be used for future improvement. This procedure is done during the designing of an improvement plan and this continues further during the operation stage. The outcomes of this analysis help an organization to design the remedial measures. This procedure can be employed by health care organizations so as to reduce or eliminate errors that arise in the process of health care provision. When an improvement plan like organizational development is implemented by a health care organization, it is important to subject it to a failure mode and effects analysis so as to determine if the are failures associated with such a plan (Cilliers, 1998). If such failures are detected at an early stage, they can easily be avoided or eliminated so as to attain the desired objectives. FMEA is therefore a process that should involve many stakeholders in the health care sector. For instance, physicians, RNs and any other support staff in the sector.

An error in medication for a patient can have varying effects to a patient; the error can either have fewer effects or can lead to permanent effects on the patient health or even death (Cilliers, 1998). The nurse therefore has a key role in determining the health of a patient; this is because the nurse delivers the medication to the patient and as well en