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Patient safety should NOT be a priority in healthcare!

Part I: Why we engage in "at-risk behaviors"

From the September 23, 2004 issue


"Patient safety must be a priority in healthcare." Most healthcare providers and consumers would certainly agree that this is true. In fact, many healthcare organizations and patient advocacy groups have fashioned mission statements, or even safety slogans, that embody this principle. The Institute for Safe Medication Practices (ISMP) is no exception. So it may come as a surprise to you to hear us say that patient safety should NOT be a priority in healthcare.

Labeling patient safety a "priority" implies that its order in a long list of other very important activities can be rearranged. It's human nature to constantly shift priorities according to circumstances and competing concerns. Accordingly, patient safety should NOT be a priority that can potentially be reordered based on the demands of a particular day or focus on a particular dimension of quality such as expediency, productivity, efficiency, and cost effectiveness. Instead, patient safety should be a value associated with every healthcare priority, linked to every activity, an enduring constant that is never compromised.1

How do you make patient safety part of your value system? Simply put, if healthcare providers voluntarily follow safe procedures consistently for every job, working safely will eventually become part of their value system. Unfortunately, this advice is not easily followed because working safely does not come naturally to people. It's often much easier and rewarding to take risks than to work safely. Fortunately, taking risks is rarely punished with patient injuries; but it's consistently rewarded with convenience, comfort, and saved time, thus creating a vicious circle of taking more and more risks. While ISMP has always urged healthcare providers to abandon "It won't happen to me" thinking when it comes to harmful medication errors, it's been difficult for many to truly embrace that attitude when, in reality, patient injuries really do seem to happen to the "other guy." This helps explain why it's an ongoing struggle to motivate people to always choose the safest way to work. Human behavior runs counter to patient safety efforts because the rewards for risk taking are immediate and positive, and the punishment for risk taking is remote and very unlikely. As a result, even the most educated, diligent, and careful healthcare provider will learn to master dangerous shortcuts and engage in at-risk behaviors.

We learn at-risk behaviors through our ongoing experiences. Remember when you first learned to prescribe, dispense, or administer medications? Most likely, you were a bit nervous and carefully followed all the safety procedures initially taught. You gave your undivided attention to the task at hand; sought out information on unfamiliar medications; prepared just one patient's medications at a time, or just one IV admixture at a time; always checked the patient's weight and allergies; educated patients about their drug therapy; asked others to double check your work; provided covering practitioners with detailed reports; and so on. But as the years went by, your complete concentration was no longer needed. Many of the initial precautionary measures fell by the wayside and you probably developed some bad habits, some at-risk behaviors.

If you're an experienced physician, for example, you may now assume you know enough about a medication to prescribe it without looking it up. You may write multiple outpatient prescriptions on the same prescription blank and offer rushed reports to covering colleagues. You may no longer review inpatients' medication administration records each day or write legible orders and discharge instructions. Upon patient admission and transfer, you may supply incomplete orders such as "take home meds" or "resume all meds." You may also have learned to use intimidating behaviors to lessen disruptions from others during your busy workday.

If you're an experienced pharmacist, you probably don't think twice about answering the phone and managing walk-in requests while entering complex medication orders. You might actually be relieved when patients sign away their option to be counseled when picking up prescriptions so your workflow is not disrupted. You may no longer check the patient's full drug profile, allergies, and weight before entering medication orders. You may now fill written medication orders using the label, not the order/prescription, and rush past drug interaction messages with barely a notice. You may no longer dispense parenteral medications in patient-specific unit doses, or ask another pharmacist to check chemotherapy solutions you prepare.

If you're an experienced nurse, you may believe it's acceptable to maintain unauthorized stashes of medications on your unit, prepare IV admixtures instead of waiting for pharmacy to dispense them, and administer medications to patients before pharmacy has reviewed the order. You may borrow another patient's medications for quick administration to your patient and leave medications at the bedside. You may no longer bring the patient's medication administration record to the bedside if you are just administering a prn medication. You may no longer take the time to label all self-prepared syringes or have mathematical calculations of doses independently checked by another nurse.

It's frightening how quickly we learn to take these and other important medication use tasks for granted. In no time at all, we have gone from a safe and controlled process, as we first learned it, to an unsafe and automatic process, the more we practiced it. The "positive" rewards for taking shortcuts rapidly foster continuance despite our knowledge on some level that it could risk patient safety. In fact, shortcuts like these could even be labeled as efficient behavior. Yet, these at-risk behaviors often emerge because of system-based problems. In part II of Patient safety should NOT be a priority (to be published in the next newsletter), we will suggest ways to uncover the underlying system-based causes of at-risk behaviors, and offer recommendations to begin the cultural transformation of making patient safety a value, not a priority, in your organization.

Reference 1: Geller ES. The Psychology of Safety Handbook. New York, NY: Lewis Publishers; 2001: 33-49.

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