October 21, 2016
Blog post by Matthew Grissinger, RPh, FISMP, FASCP, is the director of Error Reporting Programs at the Institute for Safe Medication Practices.
Health care practitioners are repeatedly challenged by unexpected problems they encounter due to both large and small work system failures that hinder patient care. A medication needed for a patient is missing on a patient care unit; an order is never received in the pharmacy; access to the automated dispensing cabinet is crowded and time-consuming; the new barcode scanner has a high rate of scanning failures; a critical drug is in short supply—the list of failures is varied and quite long, often making it difficult or impossible to execute tasks as designed.
These system failures stem from breakdowns in the environment, staffing, technology, information management, and the supply of materials within the organization. A study by Tucker found that nurses encounter almost one system failure every hour (6.5 per 8 hour shift), effectively removing one in every 15 nurses from patient care duties just to deal with the failures each day. Edmondson found that nurses spent 15% of their time (1.2 hours per 8 hour shift) coping with a tide of system failures of varying magnitudes. As a result, health care practitioners tend to be very skilled and proficient at working around these failures to get the job done. They bend the rules just a bit; they cut a corner when needed; they fail to engage the patient, their colleagues, or available technology when helpful. They fail to carry out the tasks as designed because some aspects of the tasks fail to meet their patients’ needs. In fact, these workarounds are often considered to be signs of resourcefulness, resilience, and flexibility.
The ability to address unexpected problems is highly valued in health care, especially when a patient’s life may be at risk. We expect practitioners to use critical thinking skills to navigate around systems or processes when they don’t work well in the moment. We praise and reward practitioners so skilled in using their ingenuity to work around a deficient or faulty system and still carry out tasks. We emphasize individual vigilance and encourage health care professionals to take personal responsibility to solve problems as they arise—it’s often considered a weakness to seek help.
The problem with this thinking is that workarounds merely transfer the problem to another time, person, or place. Short-term workarounds patch problems temporarily so work can be accomplished. If the problem is not fundamentally solved, it will resurface. Long-term remedies are necessary to change the underlying system and process, thus preventing recurrence.
Workarounds and nonstandard processes often take the form of at-risk behaviors by practitioners. These are behaviors where practitioners knowingly break rules but have little or no perception of the risks they are taking, or they mistakenly believe the risks are insignificant or justified. Practitioners feel forced to improvise with what they have at hand to create a solution to a problem, often without seeking help from other busy practitioners. Although at-risk behaviors are the greatest source of potential patient harm in health care, they may also benefit the patient whose care would have otherwise been interrupted, delayed, or omitted. Thus, health care practitioners are often satisfied, even proud, with their abilities to deliver patient care despite the obstacles, even when it means taking shortcuts, breaching procedures, or otherwise working around the system as designed.
Pharmacists may be able to see the risk associated with behaviors that work around the problems they encounter, and that these workarounds must be reported for analysis, learning, and system-wide improvement.
What role does pharmacy have in our organization in identifying unsafe, at-risk behaviors and what has been done to address the system shortcomings?