\f\fLatent Failures External to the Organization i. Commercialization of the health Measures to that could have been used to alleviate the problem The company could have put patient sectors in such a way that safety of safety and the quality of services as one of patients is not a priority in the its core values. This would have made industry. Every hospital sure more efforts are put in developing established seeks ways to cut on systems of dealing with errors in the cost and maximize on revenue hospital. instead of how to improve the quality of the service offered and ii. the safety of the patients Lack of strict regulations to govern practices by firms that offer health services or supply of therapeutic goods. This slap in regulations has seen companies like McKesson could engage in unlawful practices and found to have inadequate controls on its operation and still be allowed to continue to operate without any upgrading of its operations. Failures at the organizational Leadership Level i. Training lapses ah high rate of Measures to deal with the problem. i. The company should have employees turnover. Pam Golf notes the problem when she first employees especially on the area reported to work in the hospital, of patient safety. The training can indicating management be doe seminars or address by relationships with the employees ii. frequent training programs on its specialists in the field of was poor. Hiring of incompetent staff. ii. healthcare safety. The company should have had a Cornelius, as Pam Golf put it, is incompetent in mathematics and and human resource policies. The this saw her fired before getting purposes of having a sound human employment with the company. resource policy is to ensure that This shows that the company does workers are motivated to avoid not conduct background checks iii. sound human resource department excessive turnover. The when hiring. Loose procedures. Upon her department would also ensure that it is only competent individuals appointment, Pam Golf notes that the company has loose procedure, iii. who are hired in the firm. The procedures set should be meaning procedures in the organization are not strictly iv. strictly followed. The company should contemplate of forming an followed. The company lacked updated internal audit department responsible for seeing that all the policy-and-procedure manual for policies of the company are pharmacists, a documents that is followed by employees to the deemed to be like a bible for a pharmacist. iv. letter. The company should also ensure v. its policy manuals are regularly management which made the reviewed and evaluated to ensure institution lack a unified and vi. Lack of stability of tenure of top that obsolete policies do not coherent strategic direction. The hospital management had not remain on the policy papers. The company should have come v. put a unified base for writing up with a unified basis for T.P.N though the American prescribing T.N.P rather than use Society for parental and Enteral conflicting ones. It should, for Nutrition recommends so. instance, settle on use of weight of the baby as preferred by the Latent Failures at Frontline Management i. Orders meant for T.P.N were relevant association Measures to deal with the problems Management should ensure that supervisors arriving late than the prescribed time indicating supervisory failure ii. execute their duties with a professional approach. There should be a clear reporting in the organization. The supervisors had not ensured authority within the company so that those who absconds their duties are easily identified that Baxa software used to and dealt with accordingly. The Baxa accurately measure prescriptions is software should have been programmed to programmed to stop any detect and prevent a prescription error for it prescription erroneously fed into had that feature already. it. Work Place Conditions Surrounding the Event Measures to Deal with the Problems i. There was lack of trust within the Top management in the company should work work environment of the hospital. relentless to establish an environment of trust The pharmacy division manager and openness within the organizations by felt that Pam Golf was doing ii. acting as role models. It was unfortunate that things behind her back. Pam Golf, who made the mistake a divisional manager could act suspiciously to her junior for she felt threatened by her. that lead to the death of the only child of the hopeful couple, had a confrontation with the pharmacy division manager who even threatened to add her file with a reprimand letter. She also forced her to work on night shift though she had a toddler and this could be the reason behind the fatal error. Active Errors Associated with the Event i. Pam Golf feeding the prescription Measures to deal with the problem The company should seek ways of finding a machine with milligrams and not ii. machine that would ask one to confirm the micrograms. Cornelius, the incompetent staff measurement taken before it executes the request. The confirmation part can make one filled the T.P.N bag eleven times become aware of an initial mistake. More without detecting that could be an effort should be put in matching staffs to the iii. error. The staff at the nursing floor jobs that fits them well. People who lack where safety check also failed to keenness in their workers or are chronic detect the unusualness in the size jokers with less critical minds should not be of the T.P.N bag, which could assigned sensitive areas in the hospital. mean they have been allocated jobs that do not match their character, for safety checks requires people with critical mind. Latent Failures External to the Organization i. Commercialization of the health Measures to that could have been used to alleviate the problem The company could have put patient sectors in such a way that safety of safety and the quality of services as one of patients is not a priority in the its core values. This would have made industry. Every hospital sure more efforts are put in developing established seeks ways to cut on systems of dealing with errors in the cost and maximize on revenue hospital. instead of how to improve the quality of the service offered and the safety of the patients ii. Lack of strict regulations to govern practices by firms that offer health services or supply of therapeutic goods. This slap in regulations has seen companies like McKesson could engage in unlawful practices and found to have inadequate controls on its operation and still be allowed to continue to operate without any upgrading of its operations. Failures at the organizational Leadership Measures to deal with the problem. Level i. Training lapses ah high rate of i. The company should have employees turnover. Pam Golf notes the problem when she first employees especially on the area reported to work in the hospital, of patient safety. The training can indicating management be doe seminars or address by relationships with the employees specialists in the field of was poor. ii. frequent training programs on its healthcare safety. Hiring of incompetent staff. ii. The company should have had a Cornelius, as Pam Golf put it, is incompetent in mathematics and and human resource policies. The this saw her fired before getting purposes of having a sound human employment with the company. resource policy is to ensure that This shows that the company does workers are motivated to avoid not conduct background checks excessive turnover. The when hiring. iii. sound human resource department department would also ensure that Loose procedures. Upon her it is only competent individuals appointment, Pam Golf notes that who are hired in the firm. the company has loose procedure, iii. The procedures set should be meaning procedures in the strictly followed. The company organization are not strictly should contemplate of forming an followed. internal audit department iv. The company lacked updated responsible for seeing that all the policy-and-procedure manual for policies of the company are pharmacists, a documents that is followed by employees to the deemed to be like a bible for a letter. pharmacist. v. iv. The company should also ensure its policy manuals are regularly management which made the reviewed and evaluated to ensure institution lack a unified and that obsolete policies do not coherent strategic direction. vi. Lack of stability of tenure of top remain on the policy papers. The hospital management had not v. The company should have come put a unified base for writing up with a unified basis for T.P.N though the American prescribing T.N.P rather than use Society for parental and Enteral conflicting ones. It should, for Nutrition recommends so. instance, settle on use of weight of the baby as preferred by the relevant association Latent Failures at Frontline Management i. Measures to deal with the problems Management should ensure that supervisors arriving late than the prescribed execute their duties with a professional time indicating supervisory failure approach. There should be a clear reporting in the organization. ii. Orders meant for T.P.N were authority within the company so that those The supervisors had not ensured who absconds their duties are easily identified that Baxa software used to and dealt with accordingly. The Baxa accurately measure prescriptions is software should have been programmed to programmed to stop any detect and prevent a prescription error for it prescription erroneously fed into had that feature already. it. Work Place Conditions Surrounding the Measures to Deal with the Problems Event i. Top management in the company should work environment of the hospital. work relentless to establish an environment of The pharmacy division manager trust and openness within the organizations by felt that Pam Golf was doing acting as role models. It was unfortunate that things behind her back. ii. There was lack of trust within the a divisional manager could act suspiciously to Pam Golf, who made the mistake her junior for she felt threatened by her. that lead to the death of the only child of the hopeful couple, had a confrontation with the pharmacy division manager who even threatened to add her file with a reprimand letter. She also forced her to work on night shift though she had a toddler and this could be the reason behind the fatal error. Active Errors Associated with the Event i. Measures to deal with the problem machine that would ask one to confirm the micrograms. measurement taken before it executes the Cornelius, the incompetent staff request. The confirmation part can make one filled the T.P.N bag eleven times become aware of an initial mistake. More without detecting that could be an effort should be put in matching staffs to the error. iii. The company should seek ways of finding a machine with milligrams and not ii. Pam Golf feeding the prescription jobs that fits them well. People who lack The staff at the nursing floor keenness in their workers or are chronic where safety check also failed to jokers with less critical minds should not be detect the unusualness in the size assigned sensitive areas in the hospital. of the T.P.N bag, which could mean they have been allocated jobs that do not match their character, for safety checks requires people with critical mind. Latent Failures External to the Organization i. Commercialization of the health Measures to that could have been used to alleviate the problem The company could have put patient sectors in such a way that safety of safety and the quality of services as one of patients is not a priority in the its core values. This would have made industry. Every hospital sure more efforts are put in developing established seeks ways to cut on systems of dealing with errors in the cost and maximize on revenue hospital. instead of how to improve the quality of the service offered and ii. the safety of the patients Lack of strict regulations to govern practices by firms that offer health services or supply of therapeutic goods. This slap in regulations has seen companies like McKesson could engage in unlawful practices and found to have inadequate controls on its operation and still be allowed to continue to operate without any upgrading of its operations. Failures at the organizational Leadership Level i. Training lapses ah high rate of Measures to deal with the problem. i. The company should have employees turnover. Pam Golf notes the problem when she first employees especially on the area reported to work in the hospital, of patient safety. The training can indicating management be doe seminars or address by relationships with the employees ii. frequent training programs on its specialists in the field of was poor. Hiring of incompetent staff. ii. healthcare safety. The company should have had a Cornelius, as Pam Golf put it, is incompetent in mathematics and and human resource policies. The this saw her fired before getting purposes of having a sound human employment with the company. resource policy is to ensure that This shows that the company does workers are motivated to avoid not conduct background checks iii. sound human resource department excessive turnover. The when hiring. Loose procedures. Upon her department would also ensure that it is only competent individuals appointment, Pam Golf notes that the company has loose procedure, iii. who are hired in the firm. The procedures set should be meaning procedures in the organization are not strictly iv. strictly followed. The company should contemplate of forming an followed. The company lacked updated internal audit department responsible for seeing that all the policy-and-procedure manual for policies of the company are pharmacists, a documents that is followed by employees to the deemed to be like a bible for a pharmacist. iv. letter. The company should also ensure v. its policy manuals are regularly management which made the reviewed and evaluated to ensure institution lack a unified and vi. Lack of stability of tenure of top that obsolete policies do not coherent strategic direction. The hospital management had not remain on the policy papers. The company should have come v. put a unified base for writing up with a unified basis for T.P.N though the American prescribing T.N.P rather than use Society for parental and Enteral conflicting ones. It should, for Nutrition recommends so. instance, settle on use of weight of the baby as preferred by the Latent Failures at Frontline Management i. Orders meant for T.P.N were relevant association Measures to deal with the problems Management should ensure that supervisors arriving late than the prescribed time indicating supervisory failure ii. execute their duties with a professional approach. There should be a clear reporting in the organization. The supervisors had not ensured authority within the company so that those who absconds their duties are easily identified that Baxa software used to and dealt with accordingly. The Baxa accurately measure prescriptions is software should have been programmed to programmed to stop any detect and prevent a prescription error for it prescription erroneously fed into had that feature already. it. Work Place Conditions Surrounding the Event Measures to Deal with the Problems i. There was lack of trust within the Top management in the company should work work environment of the hospital. relentless to establish an environment of trust The pharmacy division manager and openness within the organizations by felt that Pam Golf was doing ii. acting as role models. It was unfortunate that things behind her back. Pam Golf, who made the mistake a divisional manager could act suspiciously to her junior for she felt threatened by her. that lead to the death of the only child of the hopeful couple, had a confrontation with the pharmacy division manager who even threatened to add her file with a reprimand letter. She also forced her to work on night shift though she had a toddler and this could be the reason behind the fatal error. Active Errors Associated with the Event i. Pam Golf feeding the prescription Measures to deal with the problem The company should seek ways of finding a machine with milligrams and not ii. machine that would ask one to confirm the micrograms. Cornelius, the incompetent staff measurement taken before it executes the request. The confirmation part can make one filled the T.P.N bag eleven times become aware of an initial mistake. More without detecting that could be an effort should be put in matching staffs to the iii. error. The staff at the nursing floor jobs that fits them well. People who lack where safety check also failed to keenness in their workers or are chronic detect the unusualness in the size jokers with less critical minds should not be of the T.P.N bag, which could assigned sensitive areas in the hospital. mean they have been allocated jobs that do not match their character, for safety checks requires people with critical mind. Latent Failures External to the Organization i. Commercialization of the health Measures to that could have been used to alleviate the problem The company could have put patient sectors in such a way that safety of safety and the quality of services as one of patients is not a priority in the its core values. This would have made industry. Every hospital sure more efforts are put in developing established seeks ways to cut on systems of dealing with errors in the cost and maximize on revenue hospital. instead of how to improve the quality of the service offered and the safety of the patients ii. Lack of strict regulations to govern practices by firms that offer health services or supply of therapeutic goods. This slap in regulations has seen companies like McKesson could engage in unlawful practices and found to have inadequate controls on its operation and still be allowed to continue to operate without any upgrading of its operations. Failures at the organizational Leadership Measures to deal with the problem. Level i. Training lapses ah high rate of i. The company should have employees turnover. Pam Golf notes the problem when she first employees especially on the area reported to work in the hospital, of patient safety. The training can indicating management be doe seminars or address by relationships with the employees specialists in the field of was poor. ii. frequent training programs on its healthcare safety. Hiring of incompetent staff. ii. The company should have had a Cornelius, as Pam Golf put it, is incompetent in mathematics and and human resource policies. The this saw her fired before getting purposes of having a sound human employment with the company. resource policy is to ensure that This shows that the company does workers are motivated to avoid not conduct background checks excessive turnover. The when hiring. iii. sound human resource department department would also ensure that Loose procedures. Upon her it is only competent individuals appointment, Pam Golf notes that who are hired in the firm. the company has loose procedure, iii. The procedures set should be meaning procedures in the strictly followed. The company organization are not strictly should contemplate of forming an followed. internal audit department iv. The company lacked updated responsible for seeing that all the policy-and-procedure manual for policies of the company are pharmacists, a documents that is followed by employees to the deemed to be like a bible for a letter. pharmacist. v. iv. The company should also ensure its policy manuals are regularly management which made the reviewed and evaluated to ensure institution lack a unified and that obsolete policies do not coherent strategic direction. vi. Lack of stability of tenure of top remain on the policy papers. The hospital management had not v. The company should have come put a unified base for writing up with a unified basis for T.P.N though the American prescribing T.N.P rather than use Society for parental and Enteral conflicting ones. It should, for Nutrition recommends so. instance, settle on use of weight of the baby as preferred by the relevant association Latent Failures at Frontline Management i. Measures to deal with the problems Management should ensure that supervisors arriving late than the prescribed execute their duties with a professional time indicating supervisory failure approach. There should be a clear reporting in the organization. ii. Orders meant for T.P.N were authority within the company so that those The supervisors had not ensured who absconds their duties are easily identified that Baxa software used to and dealt with accordingly. The Baxa accurately measure prescriptions is software should have been programmed to programmed to stop any detect and prevent a prescription error for it prescription erroneously fed into had that feature already. it. Work Place Conditions Surrounding the Measures to Deal with the Problems Event i. Top management in the company should work environment of the hospital. work relentless to establish an environment of The pharmacy division manager trust and openness within the organizations by felt that Pam Golf was doing acting as role models. It was unfortunate that things behind her back. ii. There was lack of trust within the a divisional manager could act suspiciously to Pam Golf, who made the mistake her junior for she felt threatened by her. that lead to the death of the only child of the hopeful couple, had a confrontation with the pharmacy division manager who even threatened to add her file with a reprimand letter. She also forced her to work on night shift though she had a toddler and this could be the reason behind the fatal error. Active Errors Associated with the Event i. Measures to deal with the problem machine that would ask one to confirm the micrograms. measurement taken before it executes the Cornelius, the incompetent staff request. The confirmation part can make one filled the T.P.N bag eleven times become aware of an initial mistake. More without detecting that could be an effort should be put in matching staffs to the error. iii. The company should seek ways of finding a machine with milligrams and not ii. Pam Golf feeding the prescription jobs that fits them well. People who lack The staff at the nursing floor keenness in their workers or are chronic where safety check also failed to jokers with less critical minds should not be detect the unusualness in the size assigned sensitive areas in the hospital. of the T.P.N bag, which could mean they have been allocated jobs that do not match their character, for safety checks requires people with critical mind