Answer the following 4 people with 100 words. Answer and respond to each one individually and separately. Must be 100 words each. Linae, Jejomar
LINAE: A significant real-life adverse event that occurred within the last five years involved a mediation administration error resulting in patient death at Vanderbilt University Medical Center in 2017, with organizational accountability actions and system reforms continuing through 2021-2023. While the incident occurred earlier, its regulatory actins, criminal proceedings, and national policy implications fall well within the last five years, making it highly relevant to contemporary healthcare improvement efforts. This particular event is important to me because we deal with near missed daily when it comes to giving medications daily.
Overview of the Adverse Event
The adverse event involved a fatal medication error in which a patient received vecuronium, a paralytic agent, instead of the prescribed sedative midazolam (Versed) prior top a diagnostic procedure. The nurse bypassed multiple safety checks within the automated dispensing cabinet and failed to monitor the patient after administration. The patient experienced respiratory arrest and later died. This is very concerning because as a respiratory therapist, even though we’re not responsible for giving the medications ourself, we work very closely with these types of medications when it comes to our procedures.
Impact on the Patient, Healthcare Professionals, and Organization
The most severe impact was the loss of the patient’s life, which represents a catastrophic failure in care management and patient safety. The patient’s family experienced emotional trauma and loss of trust in the healthcare system.
For the healthcare professional involved, the event resulted in criminal charges, loss of licensure, and national scrutiny, highlighting the tension between individual accountability and system-based failures. The case raised widespread concern among clinicians about the criminalization of medical errors and its potential chilling effect on error reporting.
At the organizational level, Vanderbilt University Medical Center faced regulatory penalties, reputational damage, and mandated corrective actions from oversight bodies. The event exposed systemic weaknesses in medication safety processes, including overreliance on overrides, inadequate monitoring protocols, and gaps in safety culture.
Actions Healthcare Administrators Can Take to Prevent Reoccurrence
Healthcare administrators play a critical role in reducing the recurrence of similar adverse events through continuous improvement and accountability measures, including:
- Strengthening Medication Safety Systems- Require the scanning of meds and patient before administration.
- Improving Staff Training and Competency
- Enhancing Monitoring and Escalation Protocols-Require continuous patient monitoring when giving high alert medications.
- Promoting a Just Culture – Encourage accountability for errors without fear of retaliation.
- Continuous Quality Improvement- Conduct root causes analyses and failure mode and effects analyses.
By focusing on system restructuring, leadership accountability, and fostering a culture of safety, healthcare organizations can reduce preventable harm while reporting frontline staff.
Conclusion
This adverse event further stresses the importance of continuous improvement and accountability in healthcare administration. Medication errors remain a leading cause of preventable harm, and administrators must proactively implement evidence-based safeguards. Through strong oversight, transparent reporting systems, and sustained quality improvement efforts, healthcare organizations can better protect patients and prevent future tragedies.
Institute for Safe Mediation Practices. (2021). The vecuronium tragedy: Lessons learned.
Makary, M. A., & Daniel, M, (2016). Medical error the third leading cause of death in the U.S. BMJ, 353, i2139.
Rodziewicz, T.L., Houseman, B., & Hipskind, J. E. (2023). Medical error prevention. StatPearls Publishing.
JEJOMAR: A significant adverse event that has occurred within the last five years is the retention of surgical objects during procedures, which is classified as a never event. A real-life example occurred at Albany Medical Center in New York, where at least seven cases of retained surgical items were identified between 2020 and 2025 (Times Union, 2024).
In these cases, patients were found to have surgical sponges or instrument fragments left inside their bodies following surgery. Some patients experienced ongoing pain and complications that required additional imaging, prolonged hospitalization, and repeat surgical procedures to remove the retained objects. In one instance, a retained sponge was not discovered until years after the original surgery, highlighting the severity and delayed impact of this type of error (Times Union, 2024).
The impact on patients was substantial. Retained surgical objects can lead to infection, chronic pain, emotional distress, and loss of trust in the healthcare system. Patients also faced increased physical and psychological burdens due to the need for additional surgical interventions and extended recovery times.
The healthcare professionals involved were also affected. Retained surgical items often result in professional scrutiny, moral distress, and potential legal consequences for surgeons and operating room staff. These events may damage professional reputations and contribute to burnout, especially when errors occur within high-pressure surgical environments.
At the organizational level, Albany Medical Center faced reputational harm, increased liability, and financial costs related to malpractice claims and corrective care. Repeated occurrences of similar events raise concerns regarding the organizations safety culture, reporting systems, and adherence to established surgical safety protocols (Times Union, 2024).
Healthcare administrators play a critical role in preventing the recurrence of these events. Actions that administrators can take include reinforcing strict surgical count policies, implementing standardized surgical safety checklists, and investing in technology such as radiofrequency identification (RFID) or barcode tracking systems for surgical sponges and instruments. Additionally, fostering a just culture that encourages transparent reporting of near misses without fear of punishment can help identify system failures before patient harm occurs. Ongoing education, interdisciplinary communication training, and consistent enforcement of surgical time-out procedures are also essential in reducing preventable surgical errors (American College of Surgeons, 2024).
In conclusion, retained surgical objects are preventable adverse events that can have serious consequences for patients, healthcare professionals, and organizations. Strong leadership, system-level safeguards, and a culture of safety are necessary to reduce the likelihood of these events and improve patient outcomes.
References
American College of Surgeons. (2024). Wrong surgery and retention of foreign objects remain top sentinel events.
Times Union. (2024). Albany Med mistakenly left surgical objects inside patients multiple times.
ELIZA: Change management is essential for healthcare leaders to embody because the healthcare field is always evolving with new rules, advanced technology, and the demand of patient care needs. Leaders must be able to guide their staff through these continued changes in a clear and supportive manner to avoid any confusion and improve patient safety. When change is managed effectively, their staff can understand what is occurring and why which further helps to reduce stress and resistance from change. When a leader is able to adopt good change management skills, it helps to improve teamwork, efficiency, and overall job satisfaction. They are moving their team away from outdated and stagnant processes and leading them towards more modern and efficient workflow systems. When leaders lead their team successfully through change, they are helping their organizations adapt smoothly in order to provide high quality health care to their patients. A healthcare leader can demonstrate good change management by being clear and supportive with their staff. They are able to communicate openly in regards to why change is needed, how processes will change, and how this new process is benefiting the staff and patients. Leaders are able to involve their staff in the new process by listening to their concerns, provide the necessary training and resources to implement the change. Leaders lead by example, display flexibility, and monitor how well the change is being implemented in order discover any issues and make improvements.
Commitment in healthcare leadership is important to build a foundation of trust, improving staff moral and patient safety, and providing high quality patient care. This quality shows dedication to their staff, patients, and their organization. A committed healthcare leader follows through on difficult decision, helps to support their team, work towards shared goals, and is focused on long-term improvements instead of quick fixes. An example of how healthcare leaders show commitment is when a nurse manager assists with staffing shortages. When their teammates are struggling and oversaturated with patient care, the manager helps to adjust schedules, works shifts with their staff, listens to their concerns, and helps to develop solutions to their staffing shortages. Their dedication and commitment to their team builds trust and boosts morale within the workplace.
Hills, L. (2024). Increasing Employee Commitment: 25 strategies. Physician Leadership Journal, 11(6), 3640.
Mitchell, T. (2024, December 6). Change Management: Why its so important, and so challenging, in health care environments | Harvard T.H. Harvard T.H. Chan School of Public Health.
KARRA: Good day everyone! As Dye (2022) emphasizes, effective leadership is grounded in commitment and the ability to guide an organization through the complexities of change management. These responsibilities extend beyond administrative oversight as they form the cultural foundation of a high-functioning medical environment. Similarly, Phillips and Klein (2023) highlight that impactful leaders move beyond theory by translating change into practical, actionable steps. By using structured frameworks such as Kotters model, leaders can ensure transitions are organized while minimizing initiative fatigue.
I believe one can demonstrate these principles through a balance of strategic structure and genuine empathy. For me, commitment represents a dual promise. First, an unwavering dedication to patient well-being and second, a deep investment in the growth and development of our staff. I know we can live this commitment by regularly rounding on the unit to better understand frontline challenges and by remaining steady and resilient during periods of uncertainty. As Phillips and Klein (2023) noted, staff engagement is directly influenced by the visible commitment of their leaders. When leaders remain present and consistent, it reassures the team that leadership is actively participating in the shared mission rather than observing from a distance.
One example of this approach is when we did our recent Joint Commission (TJC) inspection. Rather than focusing solely on compliance, we used the process as an opportunity to strengthen a culture of excellence. Change management strategies were applied by transforming abstract standards into daily practice through mock surveys, while commitment was demonstrated through full team engagement. Being the team lead, I remained present across all sections of our program, reinforcing the idea that, as Dye (2022) suggests, a leaders commitment is proven by standing alongside their team. I believe this collective effort empowered every discipline to confidently demonstrate our safety practices, ultimately resulting in a successful 3-year accreditation.
References
Dye, C. F. (2022). Leadership in healthcare: Essential values and skills (4th ed.). Health Administration Press.
Phillips, J., & Klein, J. D. (2023). Change Management: From Theory to Practice. TechTrends: For Leaders in Education & Training, 67(1), 189197.
Requirements: 400 words
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