This problem happened in an organization using traditional leadership structure, meaning there is one leader issuing orders from the top down; this leader is not necessarily connected with the individuals doing the work on the ground level. Due to this disconnection between leadership and workers, many times workers do not understand why decisions are being made nor do they get much feedback if those decisions are functioning properly after implementation. In addition, many times workers feel like their thoughts or suggestions go unheard or unappreciated even though they have intimate knowledge of what works best on their own unit/ward. This can lead to lack of engagement or enthusiasm which affects collaboration among teams creating further difficulties when it comes to decision-making processes (Phillips & Jennings 2003).

In contrast, high reliability organizations embrace Just Culture principles which emphasize safety and quality first while also recognizing individual contributions by allowing employees voice their opinions without fear of reprimand (HROs 2020). To address this particular problem in such an organization would require all team members working collaboratively together so that no one person has all decision-making power but rather each member’s opinion contributes toward better patient care through shared responsibility. All criticisms should be taken seriously regardless if they come from someone lower down on hierarchal ladder because everyone’s input matters when trying to provide optimal care for patients (Edmondson 2012). Moreover, everyone should be aware of their role within the team especially during time sensitive situations so that tasks are delegated appropriately according to individual strengths and weaknesses; ideally every action should be based off open dialogue involving all parties affected by change (Lapinsky et al., 2014). Finally leaders should consider implementing systems such as incident reporting programs where employees report any issues anonymously without fear of repercussions so management can identify gaps in process before mistakes occur (Levitt & Spear 2015). Such initiatives promote transparency thus creating an environment where people feel comfortable speaking up about anything concerning patient safety instead feeling intimidated due silence culture existing among some healthcare organizations today (Crowley 2016).

In conclusion effective communication is paramount within health care settings yet unfortunately breaks down more often than one would hope leading potentially harmful consequences towards patients. Traditional hierarchical structures make collaboration challenging while Just Culture values fostering trustworthiness amongst peers promotes learning opportunities while ensuring patient safety remains top priority throughout entire system . Thus adoption these tenets can help create lasting solutions addressing issues pertaining inadequate communication thus preventing future problems related miscommunications regarding medication protocols occurring same organization ever again.

References:

Crowley , E., Melli , S., & Murphy , K.(2016) The Voice Matters : What Nurses Need To Know About Speaking Up For Safety Journal Of Nursing Administration 46(9) pp 442 -447

Edmondson A.(2012) Teaming How Organizations Learn Innovate And Compete In The Knowledge Economy Jossey Bass San Francisco CA

High Reliability Organizations HROs.(2020) Retrieved From https://www2austinccedu/hr/hroshigh_reliability_organizationshtml

Lapinsky J., Laffey J,. Mehta S,. Schwartz G,. Keseg D.(2014): Transforming critical Care Through Interprofessional Practice Change American Journal Of Critical Care 23(6): 487 – 494

Levitt M & Spear P.(2015): How Can We Improve Patient Safety? Improvement Science And Practice American College Of Physician Executive 35(1): 54- 58

Phillips W & Jennings B.:2003: Leadership Characteristics Of High Reliability Organizations Military Medicine 168(5): 385 – 388