ISMP: Turn Short-Term Fixes Into Long-Term Remedies

By: The Institute for Safe Medication Practices

Healthcare practitioners are repeatedly challenged by unexpected problems they encounter due to both large and small work-system failures that hinder patient care. The list of failures is varied and quite long, often making it difficult or impossible to execute tasks as designed (Edmondson, 2004):

• A medication needed for a patient is missing on a patient care unit
• An order is placed but not 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

These system failures stem from breakdowns in staffing, technology, information management, the environment, and the supply of materials within the organization (Edmondson, 2004; Tucker, 2009). Tucker (2004; 2009) 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 each day just to deal with these failures. Edmondson (2004) 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, healthcare practitioners tend to be very skilled and proficient at working around 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 (Edmondson, 2004; Hewitt & Chreim, 2015; Tucker, 2004; Tucker, 2009; Tucker, Edmondson, & Spear, 2001).

The ability to address unexpected problems is highly valued in healthcare, 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 for using their ingenuity to work around a deficient or faulty system and still carry out tasks. We emphasize individual vigilance and encourage healthcare professionals to take responsibility for solving problems as they arise; it’s often considered a weakness to seek help (Edmondson, 2004; Tucker, 2004; Tucker, 2009).

Workarounds, however, merely transfer the problem to another time, person, or place. Short-term workarounds provide short-term solutions, so work can be accomplished. But, if the problem is not fundamentally solved, it will resurface. Long-term remedies are necessary for changing the underlying system and process, thus preventing recurrence.

Workarounds and nonstandard processes often take the form of at-risk behaviors by practitioners who knowingly break the rules but have little or no perception of the risks they are taking, or they may mistakenly believe the risks are insignificant or justified. Practitioners respond to dysfunctional processes with first-order problem solving, addressing only the immediate symptoms they encounter. They feel forced to improvise with what they have at hand to solve a problem, often without seeking help from other busy practitioners (Tucker, 2009). Although at-risk behaviors are the greatest source of potential patient harm in healthcare, they may also benefit the patient whose care would otherwise have been interrupted, delayed, or omitted (Edmondson, 2004; Tucker, 2004; Tucker, 2009; Tucker et al., 2001). Thus, healthcare practitioners are often satisfied with—even proud of—their ability to deliver patient care despite the obstacles, even when it means taking shortcuts, breaching procedures, or otherwise working around the system as designed.