In our August 7, 2007 Tip of the Week we mentioned the book by James Reason and Alan Hobbs “Managing Maintenance Error. A Practical Guide” has a particularly good discussion of violations (which are intentional deviations from standards) and the reasons for them and a useful approach that one company took to reduce them. Violations, of course, are not always bad and are often a sign that the underlying process or system was flawed in the first place. Violations and “workarounds” are very common in healthcare. In fact, we often reward people for their innovation in finding solutions to organizational barriers. However, the problem is that workarounds and other violations in the aggregate tend to promote errors and, just as importantly, a “good” workaround that solves a system problem needs to be uniformly applied wherever the flawed system is in effect rather than having multiple different workarounds ongoing in different parts of the organization.
The December 2005 Advisory from the Pennsylvania Patient Safety Authority has a good article on workarounds. That article includes a list of over 70 “at-risk behaviors” compiled by ISMP relating to medication safety. Many of the at-risk behaviors involve workarounds and apply to multiple activities besides medication safety. The list is a good place to begin your look at potential error-producing behaviors that may be amenable to change.
We recommend that during Patient Safety Walk Rounds frontline staff be asked (in a non-threatening, non-punitive manner) what workarounds they see or do themselves. Then one needs to determine the underlying reason for the workaround and attempt to develop an optimal solution that may be applied system-wide.
A second approach is the one noted in the Reason & Hobbs book in which a Swedish company tried to modify the behavior of its drivers. They assembled their drivers in small groups with a facilitator. At the first meeting they discussed general safety and quality issues and assembled a list of issues. At a second meeting they broke the list into things they had to send to management to fix and things they thought they could fix themselves. At the third and final meeting they collectively discuss the issues they felt they could deal with themselves. At the end, they write down for themselves a reminder of what they will do individually to solve the issue. The group that participated in this activity had a 50% reduction in driving accidents compared to a control group that did not participate. Interestingly, most of the group participants did not feel that the group discussions had affected their behavior. However, it is hard to deny the results demonstrated.
We therefore recommend that groups with a natural affinity (eg. those working in an ICU, or dialysis unit, or radiology department) get together to do this sort of group exercise in which workarounds and other at-risk behaviors are discussed. Your frontline workers not only know most problems better than you do – they also probably know better how to solve them!
Pennsylvania Patient Safety Authority. Workarounds: A Sign of Opportunity Knocking. PA-PSRS Patient Safety Advisory—Vol. 2, No. 4 (Dec. 2005) http://www.psa.state.pa.us/psa/lib/psa/advisories/v2n4december2005/vol_2-4-dec-05-article_g-workarounds.pdf
Update: See our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent”