Reducing "at-risk behaviors"
Part II of Patient safety should NOT be a priority in healthcare!
From the October 7, 2004
In part I of "Patient safety should NOT be a priority in healthcare" (September 23, 2004), we suggested
that patient safety should be a value associated with every
healthcare priority, not a priority that can be reordered based
on changing demands. Unfortunately, human behavior runs counter
to making patient safety a value because the rewards for risk
taking are often immediate and positive, while the punishment
(patient harm) is often remote. As a result, even the most educated
and careful healthcare provider will learn to master dangerous
shortcuts and engage in at-risk behaviors (examples provided
in part I).
System-based causes. At-risk behaviors often emerge
because of system-based problems. Unnecessary complexity in
processes provides many opportunities. To cite one, nurses
who must obtain medications from four different storage units
- an automated dispensing cabinet, a refrigerator, a patient-specific
bin containing pharmacy-dispensed drugs, and a locked storage
unit in the patient's room - are more inclined to gather all
their patients' medications each day and place them in a more
readily accessible area, including a pocket. Problems with
technology are another source of at-risk behaviors. For example,
if a physician must repeatedly wait for access to a computer
terminal for prescribing, he is more apt to give verbal orders.
If a pharmacist must back out of the order entry system to
reference a drug or a corresponding laboratory value in an
electronic database, he is more inclined to skip this step
When patient harm results, we have a natural tendency to
focus on the individuals who engaged in the at-risk behaviors.
Nevertheless, we are getting much better at identifying the
system-based causes of an event. But too often, we overlook
one of the most deeply seated roots of system problems - an
organizational culture with a high tolerance of at-risk behaviors.
Culture tolerant of risk. To uncover whether your
culture is tolerant of at-risk behaviors, ask yourself, "Does
my organization tend to punish safe behavior, and/or reward
at-risk behavior?"(1) Consider the following:
---What's your reaction to a pharmacist who takes the time
to fully investigate a "missing" medication request
during the busy morning hours, especially when compared to
a colleague who unquestioningly sends the drug to the requesting
unit? What if you're the nurse waiting for the drug, or the
pharmacy supervisor who now has to help enter the huge backlog
of orders that resulted? Would the efficiency of sending the
"missing" medication quickly offer more positive
reinforcement than fully investigating the reason for the
---How would you react to a physician who asks for help to
locate his patient's medication administration record (MAR)
so he can make sure no medications have been accidentally
discontinued upon transfer? What if you're the nurse manager
or unit secretary who must help find the MAR while managing
other important priorities? What if you're the nurse who's
using the MAR? Would the physician be appreciated more if
he didn't try to find the MAR?
---What's your reaction to a nurse who takes longer than
most to administer medications because she asks colleagues
to independently check high-alert drugs before administration?
What if you're the person who is asked to help while you have
other pressing demands? Is the nurse who does not "bother"
others praised and respected for her ability to "work
---Are your best (and safest) performers "rewarded"
with extra work? Is the most vocal person about a particular
safety problem "rewarded" with primary responsibility
to fix it? Is the lone pharmacist who always dons a gown and
gloves before entering the IV preparation area ridiculed behind
If you look closely, you will find many more examples in
which healthcare workers receive positive attention and prestige
from coworkers for engaging in at-risk behaviors.
Discipline is unproductive. Although the most convenient
way to control behavior is to create a policy and enforce
it, using disciplinary measures for a policy breach will not
result in a commitment to safety; it serves only to remind
the recipient of the top-down control, making any change in
behavior temporary. The solution is not to punish those who
engage in at-risk behaviors, but to uncover the system-based
reasons for their behavior AND decrease staff tolerance for
Increase awareness. To improve safety, it's more important
to reduce staff tolerance to at-risk behaviors than to increase
their compliance with specific safety rules.(1) So the best
place to start is to enhance staff awareness of at-risk behaviors.
Although perceptions of risk vary among people, you should
be able to identify some common at-risk behaviors by analyzing
your error reports, especially sentinel events where more
information about causative factors is available (click here
for a list of at-risk behaviors). For each at-risk behavior,
be sure a corresponding safe behavior is readily apparent
or documented. While staff who report errors may not divulge
at-risk behaviors without prompting, keep in mind, conscious
risk taking is not involved in all errors.
Learn what supports the behaviors. The most important
step after identifying at-risk behaviors is to uncover any
upside-down, consequences that lead staff to believe there
are more positive than negative rewards for the at-risk behaviors,
and possibly more negative than positive rewards for the corresponding
safe behaviors. Of course, the purpose for this step is to
identify undesirable consequences that can be reduced or eliminated.
Motivate through feedback and rewards. The next step
is the most difficult: to align individual and group motivation
with avoiding the undesired at-risk behaviors. Often, staff
motivation may be misdirected by an organizational priority
for efficiency and productivity. Another possibility is to
inadvertently reward underreporting of errors and injuries
if an incentive program is based solely on outcomes. If making
and reporting an error or injury makes someone (especially
a group) lose a reward, underreporting results. So it makes
sense to emphasize the specific behaviors that lead to patient
safety. Staff will feel more positive about the process if
the focus is on achievement rather than failure.
To start, consider asking all staff to document one at-risk
behavior and one safe behavior each day, and the conditions
under which they occurred. Collect and group these behaviors
into categories that can be identified as antecedents that
spur at-risk behaviors as well as safe behaviors. Once staff
learn the safe way to do something, and the things that enable
safe behaviors, practice is needed to make the safe behavior
a habit, and just one part of an uncompromised value system.
Ongoing support, encouragement, recognition, reward programs,
and other positive regard, especially from peers, also go
a long way. Be sure that everyone who meets behavioral criteria
is rewarded. It's better for many to receive a small reward
than for one person to receive a large reward.(1)
Conclusion. Many healthcare organizations have made
patient safety a priority that deserves their utmost attention
right now. But priorities can easily shift, and once again,
patient safety could take a back seat to other important dimensions
of quality, leaving tragic patient injuries in its wake. We
must make patient safety a sustained value, never subject
to compromise, and always driven by the ongoing quest to identify
the system-based causes of errors and the at-risk behaviors
that contributed to them. Such a quest could result in the
ultimate vision of safety in which actively caring healthcare
providers truly know what it means to be accountable for safety.
Reference 1: Geller ES. The Psychology of
Safety Handbook. NY, NY: Lewis Publishers; 2001: 33-49.