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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 busy.

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 request?

---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 independently"?

---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 his back?

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 taking risks.

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.

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