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Maintaining patient safety in the face of staff reduction

From the October 20, 1999 issue

PROBLEM:A pharmacist, who was working alone in a busy hospital pharmacy, received a stat order for oral clonidine 1 mg and levodopa 125 mg for a growth hormone stimulation test on an 8-year-old child. Despite significant pressure from the stat order and a backlog of work, the pharmacist, who was unfamiliar with the test, took time to research the information and discovered that the correct test dose of clonidine for a pediatric patient was 0.15 mg/m2. After calling the physician, the order was changed to clonidine 0.1 mg. Unfortunately, even successful outcomes like this one may not be widely appreciated if productivity is sacrificed to enhance patient safety. Nevertheless, numerous errors reported through the USP-ISMP Medication Errors Reporting Program have resulted when practitioners felt significant pressure to place productivity above patient safety, especially when faced with inadequate staffing.

Dealing with reduced staffing is a harsh reality in healthcare. Whether the situation is due to cost containment decisions to cut staff, unexpected absences, or difficulty filling open positions, inadequate staffing fosters stress and increases error potential. Compounding the problem, admini-strative actions that result in reduced staffing send an unspoken, but clear, message that crucial decisions should favor productivity. So, critical tasks such as redundancies and other standard error reduction strategies are often sacrificed to increase productivity, resulting in weakened defense systems. Even under the best of conditions, practitioners must make continuous choices between productivity and patient safety. With the added burden of inadequate staffing, they face an enormous dilemma when trying to cope with the difficult balancing act. When an error occurs, the practitioner's actions often appear as a poor gamble and disregard of patient safety.

SAFE PRACTICE RECOMMENDATION:Organizational leaders and individual practitioners share equal responsibility to protect patients from harm. Leaders must make safety an explicit goal, understand the fundamental incompatibility between productivity and safety, and emphatically reinforce that safety should not be sacrificed in favor of productivity. Before any staff reductions, leaders should allow front-line practitioners to redesign processes to eliminate some production work, not safety work such as independent check systems and other primary safety functions. Surveying practitioners intimately involved in the processes may be helpful to identify both formal and informal safety practices to assure that all critical defenses remain intact. Internal data and research in the literature regarding the relationship between patient outcomes and staffing levels also should be openly discussed and considered during process redesign. To enhance patient safety in times of unexpected staff absences, realistic contingency plans should be established and implemented.

When individual practitioners or managers believe that safe care is not possible, they should immediately notify more senior managers, describe the problem in quality and safety terms, and suggest actions to reduce risks, such as triaging phone calls, delegating tasks within the scope of practice, and redeployment of qualified staff.1 The superior's response to safety concerns and the actions taken should be documented later to maintain evidence in the event of an adverse incident and to facilitate review and organizational learning.

With continually shrinking reimbursement systems and shortages of specially trained and experienced personnel, staffing levels are unlikely to improve soon. Yet, perhaps the effects of reduced staffing have fostered a much-needed multidisciplinary approach to error reduction. Reduced staffing has forced us to acknowledge professional interdependence and the need for collaboration among physicians, pharmacists, nurses, and patients. 2 We must work together, side by side, to create safety for the system as a whole, rather than within single disciplines, departments, or units. In the face of reduced staffing, effective adaptations to enhance safety must emerge from new strategies or novel combinations of safety measures that have been previously performed only within each profession. Thus, we are now more likely to see physicians who delay elective admissions based on temporary staffing inadequacies, clinical pharmacists and patients who participate in independent checks before drug administration, and nurses who prioritize service calls to the pharmacy to minimize disruptions.

References: 1. Filipovich CC. Dealing with the issues of in-adequate staffing. Nursing 99. 1999;29:54-6. 2. Knox GE et al. Downsizing, reengineering and patient safety: numbers, new-ness and resultant risk. J Health Risk Manag 1999;19:18-25.

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