ISMP: Turn Short-Term Fixes Into Long-Term Remedies
Promote resiliency and reporting. Healthcare practitioners should be encouraged to both handle unexpected problems and then report them so steps can be taken to address the underlying causes. The challenge of workarounds is to capture their positive aspects—frontline resiliency and creativity—while simultaneously avoiding pitfalls from relying too heavily on these short-term fixes for long-standing problems (Tucker, 2004). Thus, reporting all workarounds and other temporary problem solving is crucial to delivering care as efficiently and safely as possible. Furthermore, it is possible that some workarounds are superior to existing procedures, which may require changes.
Encourage the “noisy complainer.” Healthcare leaders should create an environment of psychological safety that fosters open reporting, active questioning, and frequent sharing of insights and concerns. As noted by Tucker (2004) and Edmondson (2004), the ideal employee, at least from an improvement standpoint, is a “noisy complainer” who remedies immediate problems but also lets managers know when the system has failed. No problem is too small to report. Organizations must recognize that reporting a problem is a valid step toward improvement; sometimes merely raising the issue is the best a healthcare practitioner can do (Tucker et al., 2001). However, employees can often provide an unexplored and rich source of information about problems that, if resolved, would help reduce at-risk behaviors that can cause patient harm. On the other hand, the “adaptive conformer,” who adjusts and improvises without bothering others, inhibits organizational learning (Edmondson, 2004; Tucker, 2004; Tucker, 2009). Additional tips to improve reporting can be found in the February 9, 2006, ISMP Medication Safety Alert! (www.ismp.org/sc?id=1741).
Make communicating risk easier. Encouraging people to report and creating a psychologically safe environment for reporting are not sufficient. There must be convenient opportunities during the course of the day for workers to give feedback. Managers and leaders should establish frequent opportunities for communicating about problems with frontline practitioners. One way to do this is for managers and other leaders to be physically present in work areas and responsive to practitioner messages. Leaders can also hold safety huddles or debriefings where staff feel safe to talk about daily barriers to care, particularly if they sense the manager’s and/or leader’s commitment to resolving the issues. Moreover, discussing problems is often less threatening than discussing errors.
Examine problems close in time. Reporting system problems is also not sufficient to ensure improvement. Managers and leaders must create capacity for second-order problem solving by examining the specific problem as closely as possible to where and when it occurred (Edmondson, 2004; Hewitt & Chreim, 2015; Tucker, 2004; Tucker, 2009; Tucker et al., 2001). Important information about underlying causes of problems can be lost over time; therefore, an examination shortly after the problem occurs will likely be more productive than waiting to discuss the issue weeks or months later.
Remedy problems. Once a problem has been identified and the underlying causes examined, proper attention must be paid to reducing its recurrence. An action plan should be developed by working with healthcare practitioners who have intimate knowledge of the system’s weak points, motivation to improve its reliability, and feasible solutions. Participation in this process and problem resolution should be an explicit part of staff and leadership positions, and enough time must be allocated for improvement efforts. The action plan should be communicated to staff and then implemented expeditiously; problems that are reported but continue for weeks or months will be viewed by staff as unimportant. Monitoring to ensure the action plan is working is also crucial. Publicizing successful efforts to solve daily system problems is vital to demonstrate that reported problems are taken seriously and acted upon. This in turn will provide ongoing motivation to continue reporting problems and will encourage others to recognize the benefits of reporting.
This column was prepared by the Institute for Safe Medication Practices (ISMP), an independent, charitable nonprofit organization dedicated entirely to medication error prevention and safe medication use. Any reports described in this column were received through the ISMP Medication Errors Reporting Program. Errors, close calls, or hazardous conditions may be reported online at www.ismp.org or by calling 800-FAIL-SAFE (800-324-5723). ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. Visit www.ismp.org for more information on ISMP’s medication safety newsletters and other risk reduction tools. This article appeared originally in the May 19, 2016, issue of the ISMP Medication Safety Alert!
References
Edmondson, A. C. (2004). Learning from failure in healthcare: Frequent opportunities, pervasive barriers. Quality and Safety in Health Care, 13(suppl 2), ii3–ii9. Retrieved from www.ismp.org/sc?id=1735
Hewitt, T. A., & Chreim, S. (2015). Fix and forget or fix and report: A qualitative study of tensions at the front line of incident reporting. BMJ Quality & Safety, 24(5), 303–310. Retrieved from www.ismp.org/sc?id=1740
Tucker, A. L. (2004). The impact of operational failures on hospital nurses and their patients. Journal of Operations Management, 22(2), 151–169. Retrieved from www.ismp.org/sc?id=1737
Tucker, A. L. (2009, August). Workarounds and resiliency on the front lines of health care. Perspectives on Safety. Retrieved from www.ismp.org/sc?id=1736
Tucker, A., Edmondson, A., & Spear, S. (2001, July 30). Why your organization isn’t learning all it should. Harvard Business School Working Knowledge. Retrieved from www.ismp.org/sc?id=1738