More concrete recommendations for the organization include a clear system for assigning and determining a physician-in-charge for every admitted patient at all times, such that there is never a situation where emergency care is being directed through a cell phone, where there is not a clear hierarchy during medical response, and where there is clear accountability after the fact. Even simply signing at the top of a chart or on a room board can become an assignation of responsibility, and a simply rule that a physician must remain in the building until their patients have been signed over to someone else would ensure that care decisions are being made with immediacy and accountability in the future. More extensive training programs and requirements regarding proficiency testing should also be put into place for special types of cases before units are given actual patients, and switching out some unit staff might have been an appropriate and effective way increasing the transfer of knowledge while also increasing the level of care that Matty...

There will always be issues and mistakes, however, and these recommendations will also enable a more clear and consistent diagnosis of organizational errors and breakdowns in responsibility and communications. By identifying and maintaining a clear hierarchy and guidelines for practice and behavior, the orgnization and its patients will be much better served.
References

Bosk, C. (2003). Forgive and Remember: Managing Medical Failure. Chicago: University

of Chicago Press.

Gawande, a. (2008). Better: A Surgeon's Notes on Performance. New York:

Metropolitan Books.

Groopman, J. (2008). How Doctors Think. New York: Houghton-Mifflin.

Timmermans, S. & Berg, M. (2003). The Gold Standard: The Challenge of Evidence-

Based Medicine. Philadelphia: Temple University Press.