Patient safety

In preparing your student response, please ensure that you address the following:
Prepare a map of events accurately highlighting six (6) events and related patient safety
risks (5%)
Please note: the sixth event has been completed.
Identification of a significant patient safety risk issue that needs addressing as a high
priority. The issue should be related to cultural safety (2.5%).
Propose a feasible, evidence-based strategy to prevent this patient safety risk recurring
again in the future (17.5%)
Click here to download a template (quality improvement tool) that will to enable you to
complete the map of events from this case study. The proposal will require your own
research of current and relevant peer reviewed literature. Once you have submitted
your student response (and after the due date for this part of the task), you will have
access to an expert analysis of the case.

Case Scenario Erica’s Case

Patient safety is understood as the prevention of harm to a patient. It is aimed at
minimizing adverse events and eliminating avoidable harm in healthcare (Loza & Prince,
2015). Using Erica’s case, this paper prepares a map of events that accurately highlights six
main events and related safety risks that occurred. Also, the one significant patient safety risk
issue that has to be addressed as a high priority is identified. The issue is related to cultural
safety. Lastly, this paper proposes an evidence-based, feasible strategy for preventing the
identified patient safety risk from happening again in the future.
Map of Events
Figure 1: Map of Events highlighting the clinical risk

Erica took to
the
Emergency
Department

Long wait time in the
Emergency
Department (ED)

Patient transfer
to the OT was
delayed. The
patient was
booked for OT

Patient care
not
culturally
sensitive

Erica
worried
about being
in the
hospital for

Discharged
without medical
advice

CASE SCENARIO ERICA’S CASE 2

the previous day
evening, but she
was bumped at
the last minute

too long

The patient
presented with
iliac fossa
pain or
abdominal
pain for
investigation

Long waits in the ED
result in adverse patient
outcomes, reduced
patient satisfaction, and
trigger patient
complaints (Svagr,
2015).
There is also the risk of
death as the patient may
die on the queue while
waiting to see the
doctor. The risk of re-
admission also exists
(Lin, Patrick & Labeau,
2014). When there are
long queues and
overcrowding,
physicians spend less
amount of time with
patients. Therefore,
observation times might
be shortened, important
tests might not be
ordered, and
arrangements for
follow-up after
discharge might be
incomplete.

The patient
continues to suffer.
The longer the
patient’s transfer to
the Operating
Theatre (OT) is
delayed, the more
the patient keeps
suffering from her
illness. This is not
good for the
patient (Lin,
Patrick & Labeau,
2014).

The patient
could self-
discharge,
also known
as Discharge
Against
Medical
Advice, and
walk out of
the hospital
(Whitford &
Hubail, 2014)

There is a
risk for self-
discharge.
This is
because her
mother is
sick and
Erica is the
one who is
helping to
care for her

Risk of
readmission,
Increased risk of
mortality,
Increased risk of
morbidity,
Increased hospital
costs (McKenna
et al., 2015).
The patient was
not discharged
and thus was not
given the
necessary
medications such
as pain relief or
antibiotics.
She left without
discharge letter.
Also, no review
appointment was
arranged.

Significant Patient Safety Risk Issue: Discharge Against Medical Advice (DAMA)
One significant patient safety risk issue that has to be addressed as a high priority is
Discharge Against Medical Advice (DAMA). This is also referred to as self-discharge. It
takes place whenever an in-patient leaves a healthcare setting/hospital before the treating
healthcare provider advice discharge (Downing, Kowal & Paradies, 2014). It is a major
patient safety risk issue given that although it is rather uncommon, it is linked to mortality,
morbidity, and re-admission (McCalman et al., 2016). A patient might discharge himself or
herself from the hospital against medical advice if he/she disagrees with the management

CASE SCENARIO ERICA’S CASE 3
plan proposed by the healthcare organization. Nonetheless, in many cases, the patient might
not comprehend or not have the ability to comprehend his/her diagnosis, prognosis, as well as
the risks of self-discharging from the healthcare facility (Brascoupe & Waters, 2013).
The Aboriginal patient in the case scenario left the hospital against medical advice.
The rate at which people from Indigenous communities throughout Australia discharge
against medical advice is nearly eight times the rate of non-Indigenous Australians
(McCalman et al., 2016). DAMA is commonly linked to adverse outcomes and is widely seen
as an indicator of the responsiveness of healthcare facilities to the needs of Indigenous
Australians (Loza & Prince, 2015). While Aboriginals make up only about 2.5 percent of the
entire population of Australia, they are significantly over-represented in Discharge Against
Medical Advice situations, with one-fifth of all hospital DAMAs in Australia happening
amongst them (Renhard et al., 2014). DAMA is most widespread for Indigenous Australians
aged 25 years to 54 years and more prevalent for Torres Strait Islander and Aboriginal
peoples who live in distant and very far-off regions. Unlike non-Indigenous Australians,
Indigenous people throughout Australia have a higher likelihood of leaving the hospital at
their own risk. They also have a higher probability not to wait compared to non-Indigenous
Australians (Downing, Kowal & Paradies, 2014).
Strategy to Prevent the Patient Safety Risk from Recurring in Future
Enhance Cultural Safety in Hospitals
To successfully prevent the patient safety risk issue of Discharge Against Medical
Advice from ever happening again, an evidence-based, feasible strategy that can be used
entails enhancing cultural safety in Australian hospitals. Improvement of cultural safety has
been demonstrated as being effective in the prevention of self-discharge in Australian
hospitals. Discharge against medical advice interrupts treatment therapies and is significantly

CASE SCENARIO ERICA’S CASE 4
linked to post-operative complications as well as increased costs of healthcare (Nursing
Council of New Zealand, 2013). Evidence shows that enhancing cultural safety in hospital
organizations can help to reduce DAMA (Shaw, 2016). Cultural safety, according to Shaw
(2016), is rooted in partnership between patient and healthcare provider, wherein shared
respect strengthens improved communication between the patient and provider, treatment
outcomes, as well as health outcomes. When there is cultural safety in the hospital, patients
will feel secure and safe within the hospital environment because of shared respect,
experience, knowledge, and meaning, ensuring dignity as well as truly listening. Cultural
safety includes cultural sensitivity; that is, the sensitivity to the cultural factors of the
Indigenous patient, and considering those cultural factors (Nursing Council of New Zealand,
2013).
The recruitment and retention of Aboriginal Liaison Officers and Aboriginal Health
Workers in acute care settings throughout the country, particularly in Australia’s rural
hospitals should be increased. Aboriginal Liaison Officers refer to trained interpreters who
are intimately connected with the local communities and are independent of other staffs
within the hospital (Einsiedel et al., 2013). For Australia’s Indigenous peoples, the presence
of Aboriginal Liaison Officers and Aboriginal Health Workers has been shown to help in
enhancing cultural safety, improving patient care in hospitals, and reducing DAMA
considerably (Department of Health and Community Services, 2013). Aboriginal Liaison
Officers and Aboriginal Health Workers are well placed to assist in reducing self-discharge in
the country’s Indigenous peoples. Even so, institutional changes are required for this role to
be optimized.
Shaw (2016) pointed out that increased utilization and employment of Aboriginal
Liaison Officers and Aboriginal Health Workers in hospitals across Australia, supported by a
countrywide recognized scope of practice, could improve their capability of providing

CASE SCENARIO ERICA’S CASE 5
culturally appropriate care to Indigenous patients. Coordination between community-based
and acute care providers could help in delivering healthcare services which are not more
accessible, but also culturally acceptable (Shaw, 2016). Improved health education and
community care might encourage patients from the Indigenous communities in Australia to
remain in care throughout their treatment (Whitford & Hubail, 2014).
In their research study, Taylor et al. (2014) found that having Aboriginal Health
Workers on the wards resulted in a decrease in the number of Torres Strait Islander and
Aboriginal peoples patients who would self-discharge. They reported that the decrease in
discharge against medical advice emphasized a significant impact of the Aboriginal Health
Workers not just in improving the comfort of Aboriginal patients, but in decreasing the risks
linked to premature discharge as well (Taylor et al., 2014). Cultural safety in hospitals can
also be enhanced by improving safety frameworks culturally in Australia’s hospitals;
improving the current cultural competency training in acute care settings; and developing
more flexible community-based care models for providing culturally appropriate care for
indigenous patients (McCalman et al., 2016).
Conclusion

In conclusion, as illustrated in the Map of Events, the six main events in the case
scenario are: Erica is taken to the Emergency Department, long wait time in the Emergency
Department, patient transfer to the operating theatre was delayed, patient care not being
culturally sensitive, Erica worried about being in the hospital for too long, and patient
discharged without medical advice. The significant patient safety issue that has to be
addressed as a high priority is Discharge Against Medical Advice. It arises whenever an in-
patient leaves a healthcare setting/hospital before the treating healthcare provider advice the
patient’s discharge. One evidence-based, feasible strategy that can be used to prevent the

CASE SCENARIO ERICA’S CASE 6
patient safety issue from retaking a place in the future is enhancing cultural safety in
hospitals.

References

Brascoupe, S., & Waters, C. (2013). Cultural safety: Exploring the applicability of the
concept of cultural safety to Aboriginal health and community wellnesses, Journal
of Aboriginal Health, 34(4): 12-18
Department of Health and Community Services. (2013). Aboriginal cultural safety: An
outline of the Policy and its implementation. Northern Territory Government.
Downing, R., Kowal, E., & Paradies, Y. (2014). Indigenous cultural training for health
workers in Australia. International Journal for Quality in Health Care, 23:(3): 247-
257.

CASE SCENARIO ERICA’S CASE 7
Einsiedel, L., Macnamara, R., Iersel, E. V., & Davis, A. (2013). Self discharge by adult
Aboriginal patients at Alice Springs Hospital, Central Australia: Insights from a
prospective cohort study. Australian Hospital Association, 32(2): 51-59.
McCalman, J., Bainbridg, R., Percival, N., & Tsey, K., (2016). The effectiveness of
implementation in the Indigenous Australian health care: An overview of literature
reviews. The International Journal for Equity in Health, 15:(1) 47-52.
Lin, D., Patrick, J., & Labeau, F. (2014). Estimating the waiting time of multi-priority
emergency patients with downstream blocking. Health Care Management Science,
17(1), 88-99. Doi: 10.1007/s10729-013-9241-3
Loza, J., & Prince. J. (2015). The practical Partnering Toolkit, Prime Minister Business
Community Partnership, Department of Families, Community Services and
Indigenous Affairs, Canberra.
McKenna, B., Fernbacher, S., Furness, T., & Hannon, M. (2015). ‘“Cultural Brokerage” and
beyond: piloting the role of an urban Aboriginal Mental Health Liaison Officer.’
Public Health, 15: (61): 811-823.
Nursing Council of New Zealand. (2013). Guidelines for cultural safety, the treaty of
Waitangi, and Maori health in nursing and midwifery education and practice.
Wellington: Nursing Council of New Zealand.
Renhard, R., Chong, A., Willis, J., Wilson, G., & Clarke, A. (2014). Aboriginal and Torres
Strait Islander Quality Improvement Framework and Toolkit for Hospital Staff
(AQIFTHS), St Vincent’s Hospital. Melbourne.

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