View the scenario called “Critical Decision Making for Providers” found in the Allied
Health Community media
In a 750‐1,200 word paper, describe the scenario involving Mike, the lab technician, and
answer the following questions:
1) What were the consequences of a failure to report?
2) What impact did his decision have on patient safety, on the risk for litigation, on the
organization’s quality metrics, and on the workload of other hospital departments?
3) As Mike’s manager, what will you do to address the issue with him and ensure other
staff members do not repeat the same mistakes?
A minimum of three academic references from credible sources are required for this
assignment.
Prepare this assignment according to the APA guidelines found in the APA Style Guide,
located in the Student Success Center. An abstract is not required.
Critical Decision Making for Providers
Healthcare providers are routinely faced with dilemma (Enderlin et al., 2015). Making
the right decision depends on the consideration of the factors affecting such decisions. The case
scenario is about Mike, a laboratory technician, who is running late for work. Mike has been late
previously and his supervisor has warned him of a possible dismissal if he is late again. Upon
arrival at work, Mike comes across spillage on the floor. Mike decides to ignore the spillage and
goes on to clock in. This essay discusses Mike’s case scenario in light of the consequences of
failure to report the spillage, risks mitigation efforts and corrective measures to his behavior.
CRITICAL DECISION MAKING FOR PROVIDERS2
The Consequences of Failure to Report
The spillage endangers the safety of the patients and healthcare workers. Spills within a
hospital environment could be from hazardous drugs. Spills from hazardous drugs get into
contact through direct skin contact and vaporization (Callis, 2016). Contact with spills from
drugs leads to several adverse effects such as local skin reactions and unregulated cell division.
The decision to ignore the spill compromised patients’ safety. Falls are significant safety
concerns in hospital settings. Spills are a risk factor to patient falls. Within a hospital setting, the
risk of patient falls is further increased by the patients’ conditions and demographic
characteristics such as advanced age (Callis, 2016). Spills are categorized under environmental
risk factors that predispose patients to falls. Notably, patient falls are caused by interplay
between other several risk factors, such as taking several drugs at the same time, mental
confusion and visual and neural impairment (Callis, 2016). The rate of patient falls is used as a
safety measure in the assessment and evaluation of the quality of care offered in a given hospital.
Falls result in fractures to the bones, bleeding, pain and spinal cord and head injuries.
Patient Safety, On the Risk for Litigation, on the Organization’s Quality Metrics, and the
Workload
Environmental hazards such as spills on the floor compromise the safety of patients.
Mike, in the case scenario, does not report the spill. The risk factors to falls in the hospital
settings are divided into intrinsic and extrinsic factors. The extrinsic factors include slippery
floors (Enderlin et al., 2015). Spillage on the floor makes floors slippery. The slippery floor,
coupled with vision impairment, body imbalance, and drugs that may affect the neuromuscular
coordination will increase the risk of falls and thus compromising the safety of the patient
CRITICAL DECISION MAKING FOR PROVIDERS3
(Enderlin et al., 2015). One of the measures to prevent falls is environmental risk assessment and
modification.
The workload is directly related to the risk of patient falls. The increased amount of
work, relative to the number of workers available increases the exposure to patient falls and the
effects associated with falls (Callis, 2016).Furthermore, increased workload causes fatigue and
burn out syndrome, job dissatisfaction and poor quality of healthcare services offered. Increased
workload leads to a scenario where the workers cannot effectively monitor patients (Callis,
2016). Increased workload hinders adherence to safety measures against falls. Further, the
unattended spillage reduces the amount of time that the healthcare workers in the affected
department need to provide safe healthcare, such as screening patients for safety (Callis, 2016).
Screening for risk factors to patient falls is a comprehensive process that requires the assessment
of medication that causes postural imbalance, visual impairment and neuromuscular
incoordination (Callis, 2016).
The organization and structure of the workload affects the quality and safety of
healthcare services provided. Leaving the spills unattended causes disruptions of the work
processes in the affected department. The structure, organization and working processes have a
direct impact on the safety of patients (Callis, 2016). Further, the increase of the workload to the
healthcare workers and the supportive staff change the perception of the quality and safety of the
hospital environment. Specifically, the process of reducing hazards involves structural measures
that reduce the risks for falls, such as the reduction of the risks of slippery floors. Therefore,
slippery floors are counterproductive to the measures that reduce risks of patient falls.
Patients’ safety is a metric used to gauge the quality of care offered by hospitals. The
state governments have laid down requirements for hospitals and healthcare organizations to
CRITICAL DECISION MAKING FOR PROVIDERS4
voluntarily report risks to safety such as spillage incidents. The Agency for Healthcare Research
and Quality (AHRQ) has developed a system for reporting unsafe environments, risks, and near-
miss incidents within hospital settings (Agency for Healthcare Research and Quality, 2014).
Further, according to the provisions of the Joint Commission, healthcare providers, hospitals, and
healthcare organizations should provide evidence of safety measures for accreditation. Therefore,
the unattended spillage on the floor jeopardizes the safety of the patients and healthcare workers.
The spillage would increase the risks of patient falls. Subsequently, this would affect the
accreditation of the hospital (Agency for Healthcare Research and Quality, 2014). Similarly, the
Patient Safety and Quality Improvement Act requires all the healthcare providers to implement
safety measures that are driven by the patient and which disclose patient outcomes, safety and
improve the quality of care. Falls make up to 8% of all the cases of patient safety issues (Agency
for Healthcare Research and Quality 2014). Therefore, falls are a significant metric of patient
safety and quality of care.
Addressing the Issue
One way to address the issue in the case scenario is through education and awareness on
patient safety. Mike, in the case scenario, is a staff member of the laboratory department, an
ancillary department in the hospital. Patient falls, in the context of patient safety, are usually
addressed as a clinical issue. The healthcare professionals should appreciate that structural
factors such as slippery floors are risks to patient falls. Further, the workers should be educated
that patient falls are part of parameters used by different regulatory bodies in healthcare to
measure the safety of healthcare services. All the members of the staff in the laboratory
CRITICAL DECISION MAKING FOR PROVIDERS5
department should acknowledge the role that incidents of falls have on the health of the patients
and the outcome of healthcare in general. Further, patient falls have a substantial effect on the
accreditation status of the hospital and the healthcare organization, as a whole.
In summary, Mike’s decision to leave unattended spillage on the floor increases the risk
of falls to patients and healthcare staff. The risk of patient falls in this case scenario would be
further increased by other risk factors such as visual impairment, neuromuscular incoordination,
and poly-pharmacy. Mike’s decision has an overall effect on patient safety and accreditation
status of the hospital.
References
Agency for Healthcare Research and Quality. (2014). 2013 National Healthcare Disparities
Report. Rocksville:
Callis, N. (2016). Falls prevention: Identification of predictive fall risk factors. Applied nursing
research, 29, 53-58.
CRITICAL DECISION MAKING FOR PROVIDERS6
Enderlin, C., Rooker, J., Ball, S., Hippensteel, D., Alderman, J., Fisher, S. J., … & Jordan, K.
(2015). Summary of factors contributing to falls in older adults and nursing implications.
Geriatric nursing, 36(5), 397-406.