Tuesday, March 31, 2009

"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!


Reality Rounds said...

Hi Barbara,
I work in the extremely high risk areas of L&D and NICU. I have never encountered a "fail safe" safety intervention. Nothing is ever really fail safe, is it? Thankfully NICU's have some of the lowest med errors, but when errors happen, they are devastating. Bar coding is great, but not fail safe. I wish you had mentioned staffing ratios in your post. Nurses are being pushed to the edge. Repeated studies have shown the lower the staffing ratios, more errors happen. I wonder if the FAA would let a plane fly if they had only one pilot and no flight attendants?

Barbara Olson, MS, RN, FISMP said...

Thanks for making the comparsion between aviators and healthcare workers! Not only would the FAA not allow the plane to take-off, the crew wouldn't go! (Great example of what a "culture of safety" really looks like, although I would image that the motivation to work within a highly reliable system is greater when professionals are "at the same altitude" as the folks they're responsible for!) Appropriate staffing is certainly a component of delivering the intended outcome, something I'll be chatting about here at Flo dot com.
Thanks, too, for the observation that "fail-safes" can be worked-around. Higher-order strategies are less likely to fail, because they require greater effort on the part of humans to derail them. But where there's a will, there's probably a way. Here's a Wiki address for Poka-yoke, which describes the concept of fail-safes: http://en.wikipedia.org/wiki/Poka-yoke if you're interested. I thought it was interesting that the Japanese term was re-worked to better describe it!

Kristine RPh said...

A good reminder of how often we hear "more education" or "be more careful" as the answer to how an error could have been prevented. This is a ranked list that all HCP's (at every level) should be aware of.

Another great post!

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