"Here's Your Sign" is not a High-End Risk-Reduction Strategy. Go Figure.

I live in the southern part of the U.S., and, like most of my friends, I like Bill Engvall, one of the funny men on the Blue Collar Comedy tour. Larry the Cable Guy, not so much, but I really think Bill Engvall is funny. If you don't know who he is, here's one of Engvall's jokes (and a link that takes you to the lyrical version of "Here's Your Sign"):

A couple of months ago I went fishing with a buddy of mine, and as we pulled his boat into the dock, I lifted up this big 'ole stringer of bass.

This idiot on the dock goes, "Hey, y'all catch all them fish?"

"Nope. Talked 'em into giving up."

I like Bill Engvall’s take on the human condition. It helps me make it through the Walmart. But when I go to work, I try to leave Bill behind. Here’s why:

In Chipping Away at Risk, I talked about how professional standards in other industries call for the use of the highest feasible strategies to manage predictable risks, and noted that similar thought processes are not yet considered "the norm" in the healthcare culture. In healthcare, it’s easy to draw from our duty-oriented traditions, falling back on what an “A player” wants to do on a good day rather than what a “B player” produces on an average day. (We will not discuss "C players" today.) But Human Factors research tells us that different, more reliable processes are needed to manage predictable risks that arise when people, processes, and equipment converge: "Hey, y'all catch all them fish?"

So here’s a user-friendly list of risk reduction strategies, one that’s widely used by the safety analysts at the Institute for Safe Medication Practices. The strongest error-reduction strategies are listed first, with the less effective options lower on the list:

• Fail-safes & Constraints
• Forcing functions
• Automation & Computerization
• Standardization
• Redundancies
• Reminders & Checklists
• Rules & Policies
• Education & Information
• Suggestions to be more careful or vigilant

And three examples showing how these principles look “on the job”:

1. A patient care unit where the primary fall-prevention intervention involves nursing personnel “keeping a close eye on patients at-risk to fall ” is using a less reliable fall-reduction plan than a unit where nursing vigilance is augmented by standard measures (such as the opportunity to use the bathroom every two hours). This can be predicted because scheduled opportunities to use the bathroom standardizes an intervention while “keep a close eye on them” relies on personal vigilance, a much weaker risk-reduction strategy.
2. A neonatal unit that has a policy stating only 10 units/mL heparin will be stocked in the unit’s automated dispensing cabinet (ADC) has a less reliable risk-reduction plan in place than a neonatal unit where heparin products undergo bar-code scanning prior to delivery to the unit and prior to being prepared for a given patient. Bar-coding is an automated risk-reduction strategy with reliability that trumps both policy statements and the accuracy of humans when “reading the label.”
3. Port-free epidural tubing, especially those with distinguishing colors and features, makes patients safer than using standard IV tubing because the absence of a port is a constraint that can prevent inadvertent administration of parenteral drugs to the patient’s CNS, a tragic occurence that regularly happens when well-educated clinicians become distracted.

I hope the rank order of risk reduction strategies and the clinical examples give you something useful to consider about mitigating on-the-job risks and how to respond when an error occurs.

Stay safe, find some time to fish, and come back soon!