Stopping workarounds means changing culture
Open culture will let you measure the problem
What do you think are the top medication administration workarounds in your hospital? Can you guess? Have you tried to figure it out? Maybe you think you don’t have that problem. You’re probably wrong, says Beth Boynton, RN, MS, a nurse and consultant who works in New England to help hospitals and their staff change bad habits and embed new ones. Here is her list of some of the top workarounds she has seen in her years as a nurse.
- relying on memory from earlier in the day or previous shift for some steps;
- stopping in the middle of the process to answer an alarm and then, rather than restarting the process, picking up where you thought you left off;
- trusting that the pharmacy sent the right dose or medication and not checking yourself;
- gauging timing as "close enough" or "maybe the only opportunity"
- the patient is sleeping and the nurse doesn’t want to wake him or her;
- there is dried-up pasta sauce on the bracelet bar code or the scanner isn’t working, or someone else has it.
Most of these, Boynton says, don’t lead to problems for patients. But they are, in and of themselves, errors.
While a lot of what is done related to medication administration is governed by checklists and automation and barcodes, there is plenty of room for workarounds and mistakes, she says. "People will always find a way to do something wrong. If you think about using a scanner and you scan the patient and med, it takes a couple seconds. But if you are interrupted, and you have to stop and attend to someone else, do you come back and do it again, or do you save those couple seconds and just give them the medication? And if you want to give it later, what if you forget?"
One nurse in the neonatal intensive care unit told her a story once about using scanners that were "temperamental." So they developed a workaround. Well, what if the workaround became so convenient that you found a way to make that scanner permanently temperamental? "We, as nurses, are always struggling to get through our shift. We have 100 things to do but can only manage to get 80 done if we do it right, but 90 if we use workarounds, what do you think we’ll be inclined to do?"
If you want to find out what your workaround issues are — and you should — you have to start by asking questions. But there’s a chicken-and-egg problem here. Because Boynton says if you don’t have a just culture that is warm and open to anyone speaking up and speaking out, you aren’t going to get the information you need to identify problem areas and then solve them.
She tells the story of one organization that knew it had some problems with medication administration workarounds. It sent out a survey asking nurses what the problems were. The response rate was abysmal because nurses felt one of two things would happen — they would be punished for being honest or, nearly as bad, the hospital would take the information and do nothing.
"The first issue is getting to the truth. Once you have a culture where you can do that, then you have to determine the magnitude of the problem." While she thinks a just culture would probably have less of a problem with workarounds — people would speak up and say there was a problem, call others they see using workarounds on their behavior, and work together to find solutions — they undoubtedly still exist. "They aren’t always bad; because we are by nature in a state of nearly constant crisis, a shortcut can be a lifesaving thing sometimes. But for the most part, they are bad habits, and it’s a good idea to minimize them as much as you can," Boynton says.
Some may be a matter of muscle memory that comes from 30 years of doing something one way before someone instituted a change. Some may be a faster, better way of doing something that deserves a hearing. Some might be laziness.
"Sit down and ask people," Boynton says. Use informal discussions, or if you are looking to measure problems, create a survey. You need to ask them about the areas of concern, the places where they are using shortcuts or have seen others use them or wish they had them. You should ask about areas that are pitfalls and persistent problems. But don’t ask them, "Why don’t you do this?" Boynton suggests that you instead ask, "What do you need to do it right?"
Some solutions are going to be easy, she says. Think of the hand-washing problems that are solved by having more paper towel dispensers, for example. But some will be harder. A lot of what is wrong with nursing care, says Boynton, relates to staffing levels. More staff — whether it is administrative to reduce interruptions or clinical so that there those 100 necessary things can get done on a given shift — takes money that a lot of organizations will say they don’t have.
Make part of your process understanding what kind of resources it takes to do things the right way every time. Not just in terms of people, but time. Figure out how long it really takes to do things in a real-world environment — like on a busy Saturday night in the ED or Tuesday afternoon on the med/surg unit. Test out education materials on real patients — including the ones who are hard of hearing and left their hearing aid at home. Have this kind of data available, along with the information on workarounds, and you should be able to come up with some workable solutions.
And if you have a truly just culture, with a leadership that is willing to hear hard messages, a solution to medication workarounds that requires more staff is something that will be heard with respect.
For more information on this topic, contact Beth Boynton, RN, MS, Portsmouth, NH. Telephone: (603) 319-8293.
