Identification and Description of the Issue The first aspect of risk, reducing harm to patients, incorporates …show more content…
Compromised patient safety and organizational liability result in higher health care cost to patients and institutions requiring the need for improvement. Hospital-associated infections (HAI) are preventable; however, over one million occur each year across the United States (Agency for Healthcare Research and Quality, 2014). According to the World Health Organization (2017), “Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world” (para. 1). “Many studies have shown that the majority of errors occur because of a failed system rather than irresponsible human error” (Lewis, Baernboldt, and Hamric, 2013, p. 153). Medicaid and Medicare Services penalize organizations financially by providing reduced reimbursement when HACs are reported (Centers for Medicare and Medicaid Services, 2015). Nurse leaders, financially accountable for identified implications, have a direct impact on reducing errors and potential …show more content…
The butterfly effect occurs when the changes lead to the emergence of unpredictable consequences. These issues, fundamental to risk management, require an interdisciplinary system approach to pull the system toward a common attractor of safe and quality nursing care. A transformational nurse supports a dynamic, self-organized system and integrates change and leadership theories (Smith, 2015). Coherence is established and the larger system adapts once behavioral changes occur. Burns’ transformational leadership theory can be described as the process in which leaders and followers collaborate to achieve cultural change within an organization (Ross and Fitzpatrick, 2014). Transformational nurse leaders are dedicated to assisting staff in adapting to the continuous changes that occur in healthcare and support risk management. This theory can be used to work towards the benefit of creating cultural changes that improve risk assessment and management. The organizational development theory is the process of improving the organizational climate through change. Organizational climate, the mood of the institution, is created by employee attitudes and beliefs (Schneider, Ehrhart, and Macey, 2013). Climate is impacted when nurse leaders portray open communication, transparency, support, and