MHA 542 Week 2 Leading in Complex Environments: Transparency and Vulnerability Example

Telling the Family and Telling the Staff: Transparency, Vulnerability and Psychological Safety After a Serious Medication Error

[Student Name]

University of Phoenix

MHA/542: Leading with Authenticity in the Health Sector

Week 2 Assignment

[Instructor Name]

[Date]

The medical center, the error, the people involved and the responses are composites written for a model paper; research findings come from the sources cited.

At 11:40 on a Friday night, the same western Michigan medical center's chief operating officer received a call from the nursing supervisor. A patient recovering from surgery had received ten times the ordered dose of a blood-thinning medicine after a decimal error in a pharmacy compounding record, and had been moved to intensive care with bleeding. The patient was stable but would need several more days in the hospital. By Saturday morning, the chief operating officer faced two questions: what to tell the family, and what to tell the staff. This paper examines both through the lens of authentic leadership.

A Complex Environment

The situation was complex in the technical sense: causes were not yet known, several departments were involved, the legal and regulatory consequences were uncertain and emotions were high. No procedure could fully determine the right response. Complex situations call for leaders who act on values while learning as they go.

The Pull Toward Silence

The chief operating officer felt pressure from two directions. The risk manager advised saying as little as possible until the investigation was complete. The pharmacy director worried that discussing the error openly would shame the pharmacist involved. Both concerns were sincere. Both pointed toward silence.

Transparency With the Family: The Evidence

Evidence suggests that openness does not increase legal risk. When a university health system in Michigan began telling patients about errors, apologizing and offering compensation where care fell short, new claims and lawsuits both dropped sharply, claims were resolved faster and total liability costs fell by more than half, although the study could not prove the program caused the changes (Kachalia et al., 2010).

The Family Meeting

On Saturday afternoon, the chief operating officer, the attending surgeon and the chief nursing officer met the patient's wife and adult son. They explained what had happened in plain language, said that it was the hospital's error, apologized without qualification and described what was being done to care for the patient and to understand how the error occurred. They promised to share what they learned and named a single contact person. The family was angry and grateful at once.

Transparency With Staff

Rumors had already spread. Nurses on the surgical unit feared blame for not catching the dose; the pharmacist was on leave, distraught. Saying nothing would leave staff to fill the silence with fear.

Why Staff Silence Is Dangerous

Research on work teams found that team psychological safety, meaning members' shared confidence that they can admit mistakes or raise concerns without being punished or embarrassed, was associated with learning behavior such as seeking feedback, discussing errors and asking for help (Edmondson, 1999). In health care, staff who fear blame stop reporting near misses, and the next error becomes more likely. How a leader responds to the first error decides whether she hears about the second.

Status and Speaking Up

Hierarchy makes speaking up harder for some. A study of 23 neonatal intensive care units found that professional status was associated with psychological safety, with physicians feeling safer than nurses and respiratory therapists, and that leader inclusiveness, meaning words and deeds that invite and appreciate others' contributions, strengthened psychological safety and narrowed the status gap (Nembhard & Edmondson, 2006).

The Staff Forum

On Monday, the chief operating officer held forums on each shift for surgical and pharmacy staff. She described the facts known so far, said that the investigation would look at systems, not hunt for someone to blame, and asked what they had seen that might help. She invited pharmacy technicians and nurses to speak first.

An Act of Vulnerability

At each forum, she told a story she had rarely shared: as a young operating room nurse, she had once miscounted sponges, and a sponge was nearly left in a patient. A colleague caught it. She described how ashamed she had felt and how the surgeon's response, thanking the colleague and asking how the count process could be improved, shaped her career. Her point was that everyone makes errors, and the question is whether the system and the people around them catch them.

Servant Leadership in Practice

She also visited the pharmacist at home, with the pharmacy director, to express support and explain the process. Caring for the second victim of an error is part of serving staff.

What Staff Said

The forums surfaced information the formal investigation might have missed: the compounding software allowed free-text dose entry, the pharmacy was short-staffed on Friday evenings and two similar near misses had occurred and not been reported.

Acting on What Was Learned

The root cause analysis confirmed the software and staffing issues. Dose fields now reject values outside set ranges, a second pharmacist checks high-risk compounded medicines and Friday evening staffing increased. The chief operating officer reported these changes to the family and to staff.

Keeping the Promise to the Family

The hospital had promised the family to share what it learned. Three weeks later, the chief operating officer and the surgeon met them again, explained the software and staffing causes and the changes made, and discussed compensation for the extra hospital days and the son's lost work time through the hospital's disclosure program. The patient's wife said the second meeting mattered more than the first, because it showed the hospital had kept its word.

Protecting Just Culture

Transparency does not mean no accountability. The investigation found that the pharmacist had followed the process as designed, so no discipline followed; had she knowingly bypassed a safety check, the response would have differed. Explaining this distinction to staff helped them see that openness and accountability can coexist.

The Risks Were Real

Openness had costs. One manager felt the forums undermined his authority. The risk manager remained uneasy. The chief operating officer acknowledged these concerns directly rather than dismissing them.

Teaching Other Leaders

The chief operating officer asked the medical center's directors to hold similar conversations after serious events in their areas and offered a short guide: state the facts, say what is not yet known, invite those closest to the work to speak first, protect the people involved and report back on changes. Two directors used the guide within the next two months.

Measuring Whether It Worked

She set measures: medication near-miss reports, safety culture survey results on speaking up and nonpunitive response to errors and the time from event to disclosure. In the following quarter, pharmacy near-miss reports rose by 40%, which the safety team read as increased willingness to report rather than more errors.

Conclusion

A serious medication error tested whether the chief operating officer would lead with transparency and vulnerability or retreat into silence. Evidence on disclosure programs, psychological safety and leader inclusiveness supported openness with the family and staff. Telling her own story of error turned the forums into a lesson in learning, and the measures that followed suggested staff heard it.

References

Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350-383. https://doi.org/10.2307/2666999

Kachalia, A., Kaufman, S. R., Boothman, R., Anderson, S., Welch, K., Saint, S., & Rogers, M. A. M. (2010). Liability claims and costs before and after implementation of a medical error disclosure program. Annals of Internal Medicine, 153(4), 213-221. https://doi.org/10.7326/0003-4819-153-4-201008170-00002

Nembhard, I. M., & Edmondson, A. C. (2006). Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior, 27(7), 941-966. https://doi.org/10.1002/job.413