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