Problem
Central Town Hospital was founded in 1889 as a non-profit, community-based health care facility in Prince Edward Island. This 116-bed acute care facility employs 963 employees and is nestled along the Susquehanna River's northern branch in Briar Creek. The facility provides general medical and surgical services to the surrounding community of approximately 70,000 people. The hospital is proud of its tradition of upholding its mission to these communities by providing comprehensive health care services in a compassionate, caring, and cost-effective manner while maintaining the highest level of professional excellence. The hospital is in the process of a year-long celebration commemorating its 125th anniversary by partnering with the community for free monthly health screenings, hosting a summer carnival on the hospital's grounds, and reaching out to local community health centers to provide free health education and health care services to homeless clients, such as assessment.
You were recently hired by Central Town Hospital and taking the position as a leader to manage the teams and respond to the crisis events.
This case study focuses on an adverse event and as a leader, tell me how you manage the following situation.
One of the first things I learned after being appointed hospital manager was to deal openly with patients and families (and the community) when we made mistakes. Here's one example that has always stuck with me:
A 6-year-old patient with a defect in bowel function was hospitalized for severe constipation. He was given a dose of neostigmine (a drug that helps muscles contract and relaxes to move food through the system) that was 10 times the average amount because of a decimal point error made by the resident who ordered the drug. Instead of 0.4 mg, the patient received 4.0 mg.
Tragically, the patient died the same day from the overdose.
My human resources director advised me to hold a press conference to announce our mistake immediately. I did. The meeting lasted two hours and centred on reporter questions about why the resident and nurse had not been fired. I explained that both were highly regarded, and that the problem was a "system" problem, not a problem of an incompetent physician or nurse. I explained that we should have a fail-safe system to prevent such a mistake. (Today, hospitals have electronic medication error avoidance systems. We didn't have that in 1984.)
I indicated to the reporters that we would be examining the medication administration procedures in place from the point the medicine is ordered to the time it was given and would put a process or procedures to ensure that such an error would not happen again.
This story contrasted sharply with an experience I had with a wealthy patient from Geneva, Switzerland, who came over to Canada each year for a comprehensive examination.
Before coming to Prince Edward Island after his overseas flight, his routine was to spend a few days in New York City and visit friends. He fell while walking along a street in New York on one such annual trip, fracturing his pelvis. He was admitted to a well-known hospital and spent three weeks recovering in bed.
I received a call from him asking to be transferred to Central Town Hospital. He was unhappy with his care, indicating that no one seemed to be attending to him. We arranged the transfer and, when I saw him that afternoon, I was astounded to find that he had a pressure ulcer on his heel that was an inch deep. The ulcer wouldn't heal, so I secured a vascular surgeon to perform arterial bypass surgery. The surgery, which improved circulation in the patient's leg, was successful and, after weeks, the ulcer healed completely.
Your task is to respond to the following questions.
What is the difference between the two stories, and why were they handled differently?