Patient Safety Tip of the Week
September 4, 2007
Workarounds as a Safety Issue
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!
References:
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”
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