The Broken Button

February 17, 2016 by   |   Leave a Comment

I’ve been having some trouble with the garage door opener for the last 6 months. There’s an indoor button that fails intermittently. Since it’s not happening every day, I’ve resorted to using a workaround which means going to my car and pressing the button above the console instead of just fixing the button. I’ve found myself, more times than I care to share, cold and in the rain shivering, rather than going on-line or making a call to get what I need. In the moment, it just feels easier to do it the way I’m doing. You would think I’d gotten the message. But I haven’t. I’m still putting up with the broken button. This is a great example of a work around.

Why are healthcare workers known as “masters of workarounds”? Why do we continue to do them, even when we know we shouldn’t? The answer might surprise you.

According to some researchers, nurses experience an average of one “operational failure” an hour in a typical health care setting.  According to Anita Tucker M.B.A,. this in effect, increases their workload from 5 patients to 5.3 patients a shift. In her 2009 essay, Workarounds and Resiliency on the Front Lines of Health Care, (link below) she argues that workarounds are embedded in health care culture and that they actually help to make people feel better.  They enable the individual who sees the problem to take matters into their own hands, allowing them to continue working without interrupting others.

She notes: “…workarounds tend to be viewed positively as creative, patient centered care by both providers and managers.”

Often, at first blush, work arounds can seem helpful. They allows processes to continue, offer a personal sense of accomplishment and don’t burden others. They also seem to take care of the immediate patient at hand.  Unfortunately, they are often done without others knowing, which can lead to unintentional harm of a patient and also prevent the real problem from being tackled. A lack of communication also unwittingly pushes the problem from one arena to another – a downstream effect which can lead to misperceptions of shortages or effectiveness when something is broken. So, workarounds decrease safety, and prevent better solutions from emerging. At the very least, it also decreases the spread of a good idea.

Root cause problem solving is a proactive approach which includes communication about the problem to individuals who can do something to remove the problem, create countermeasures or allow for intentional experimentation.

Real time and root cause problem solving have been found to be essential in mitigating work arounds. This is why the Be Safe Event reporting and the A3s are so important and why these approaches yield the safest solutions.

So, the next time you see a problem that is something that is crying out for help, call for some assistance in identifying the root cause and stay away from the workaround.

cg

Link to essay:   https://psnet.ahrq.gov/perspectives/perspective/78

(thanks, to Posy Marzani for helping me with this blog)

Filed Under: BeSafe

 

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