NR-360 Week 4 Discussion: Workarounds and Their Implications for Patient Safety (GRADED A)

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NR-360 Week 4 Discussion: Workarounds and Their Implications for Patient Safety 1. What is a workaround? Identify a workaround (specific to technology used in a hospital setting) that you ... have used or perhaps seen someone else use, and analyze why you feel this risk-taking behavior was chosen over behavior that conforms to a safety culture. What are the risks? Are there benefits? Why or why not? 2. Discuss the current patient safety characteristics used by your current workplace or clinical site. Identify at least three aspects of your workplace or clinical environment that need to be changed with regard to patient safety (including confidentiality), and then suggest strategies for change. Discuss the current patient safety characteristics used by your current workplace or clinical site In many jobs and institutions, they have safeguards with technology that allows the maximum safety of patients. These safeguards are integrated with technology to provide safety. For example, of these safeguards could be passcodes that nurses use in certain situations to protect their identity and keep records of their activity. For instance, the safety characteristic at work for nurses is when they must punch in a code to go into a supply room. Also, nurses must use code in order to use the MAR and Pyxis to provide medication to patients. In addition to that nurse is also having to scan the medication and read certain prompts on the computer before they can administer the medication. Another safeguard with technology that nurses must do is follow the 6 rights of medication administration. It is the nurse’s responsibility to double check the name the date and other details on the computer before giving medication. It is important for nurses to keep these past codes private because other nurses and he even clients can use these codes and abuse them. It is for the client’s safety that nurse protects their passcodes in the hospital and read all prompts on the computer before administering medication to prevent medication errors. I can understand that technology is becoming more complex in the medical field. Many nurses may become frustrated when they must enter passcodes or safeguards to give medication, clocking into work or entering a supply room. However, according to our textbook in chapter 11, many nurses create workarounds and, “if at all possible, will design workarounds that allow them to circumvent troublesome technology. However, workarounds are only a Band-Aid; they are not a long-term solution” (McGonigle & Mastrian, 2018). Therefore nurses will make sure cuts to make their job easier. Identify at least three aspects of your workplace or clinical environment that need to be changed with regard to patient safety (including confidentiality), and then suggest strategies for change. 1.) During my clinical experience, I notice that many nurses when providing medication to their clients do not read all the prompts on the computer. Also, they do not follow the 6 rights of medication administration. For example, when you provide medication to a client in their room certain prompts appear to show you certain side effects and considerations. Although I know nurses must be familiar with many drugs, they should still be aware and take their time to read the considerations for drugs that they are not familiar with. Also, the nurses don’t follow these 6 rights of medication because once they grab the correct medication from the medication room sometimes, they don’t double check the patient’s information and ID before providing the medication to the patients. Furthermore, under the U.S Department for health care Research and Quality an article was written by Tucker she states, “staff repeatedly work around safety-related warnings to obtain and administer excessively large doses of medications rather than contacting the pharmacist or the physician” (Tucker, 2009). This is another problem with medication administration because nurses are not reading the warning prompts on the computer and simply administer the medication as quickly as possible. In order to fix this, you will have to understand why Nurses are trying to save time during medication administration. One possible cause for why nurses are not following all the prompts on the computer before administering medication is because maybe the computers are slow and old. The nurses weren’t reading all the prompts on the computer before providing medication not because they were lazy. But because they were saving time. When are nurses busy and have to provide medication to multiple patients sometimes the computer can be slow and it can impede workflow. A simple fix to this would be providing newer and faster computers. 2.) I have thought of another possible workaround in the hospital. Although I have never seen a nurse do this. I have thought that it is possible for nurses to do this to save time. What I’ve noticed that nurses must enter many access codes to enter certain rooms. For example, nurses frequently must start an IV and every time they need to start an IV they need to enter an access code to go into the supply room. Although I know it would be extremely reckless, I thought about putting in a door stopper in the supply room so I wouldn’t have to enter a passcode every time. The reason why I thought about this is that they are different access codes for different supply rooms and I was getting frustrated that I was forgetting the different access codes. In order to resolve this issue, I thought it would be very beneficial if the supply rooms had fingerprint sensors on them. Much like how our modern cell phones today can use your fingerprint to access our cell phones faster than punching in the code, we can use the same fingerprint technology for nurses to go into supply rooms faster. This will help prevent workarounds because nurses would be able to access rooms faster while maintaining security. 3.) In my last example, I have noticed that it is difficult to scan certain bar codes on patients and on certain medications and supplies. I understand that the bar code technology is necessary because it helps to keep track of medication administration and other records. But sometimes it is very difficult to scan the bar code. According to your textbook in chapter 11, it states, “nurses devised workarounds, such as removing the armband from the patient and attaching it to the bed, because the bar-code reader failed to interpret bar codes when the bracelet curved tightly around a small arm” (McGonigle & Mastrian, 2018). In this example, nurses can have difficulty scanning a barcode on a child. A nurse may devise a workaround by scanning removing their identification bracelet to scan it easier. Although this may save time, clients can be misidentified if nurses remove armbands too frequently. To fix this and nurses can request that bar code readers be replaced. Sometimes it’s not the nurse’s fault for why technology is not working. Instead of using shortcuts such as removing the identification armband, it would be better for the patient safety to request newer and more advanced bar code readers. Although this may sound like an expensive solution, It is still better than waiting for a lawsuit because you miss identified a patient after a nurse decided to remove their identification armband to scan it. Works Cited McGonigle, D. & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge. (4th edition). Burlington, MA: Jones and Bartlett. Tucker, Anita L. “Workarounds and Resiliency on the Front Lines of Health Care.” PSNet, (2009) retrieved from psnet.ahrq.gov/perspectives/perspective/78/workarounds-and- resiliency-on-the-front-lines-of-health-care. Paola Torres Hello professor and class, According to our textbook, workarounds is described as "Increasing demands on professionals in complex and fast-paced healthcare environments may lead them to cut corners or develop workarounds that deviate from accepted and expected practice" (McGonigle & Mastrian. 2018. p. 453). In other words, this means that is a short cut or cutting corners to get the job done faster. I witnessed an interesting but troublesome workaround. A nurse was using a new barcoding system to perform medication administration. The bar code on one unit-dose medication would not scan properly because of a crinkle in the barcode. The nurse was to then manually input the barcode from the package onto the system computer. However, the print on the barcode was too small for her to read. She then prepared to cut and paste the medication number from the computer screen into the manual entry input box. That, of course, would have bypassed the whole patient safety concept of a barcoding system, which is to verify that the medication being given is the same as the one on the computer screen. Simply typing in those same numbers seen on the computer screen would have also bypassed the safety mechanism involved in barcoding. On my clinical site, one workaround that I see a lot is counting medication after getting one. I was once shadowing my nurse when we went to get a medication that is a narcotic and when she took it she just recorded the number of the medication left without counting. I asked her why she did no count those pills left and her response was " we have too many patients today to be counting". I was in shocked; I could not believe it but I stayed in silence and kept doing what I was suppose to. I then reported to my clinical instructor hoping not to get no one in trouble. Another workaround that I see in my clinical sites is the charting; nurses write everything so fast to save time and get everything done that sometimes you can't even understand what does it say. Then they tell you to go put it on the computer for the records and i catch myself going back to them to ask them what does the scrabble means. If I wanted to, I could just write whatever I think it says in the paper. I think that even though you are going fast you should right clear for the sake of your patient and yours. When we talk about medication many, many, but many times I have seen that nurses do not double check the order to make sure is the right medicine for the right patient. Medical error is a major concern in healthcare, it is insane to think that you can kill one person just for a simple workaround. Sometimes hospitals load nurses with many patients leading them to commit this errors. I found an article that talks about a medical error due to overwork. A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospitalization, he was transferred to a skilled nursing unit to complete antibiotic therapy. Cancer chemotherapy was scheduled to begin after discharge.Three days after transfer to the skilled nursing unit, the patient complained of nausea. Intravenous ondansetron (Zofran) was ordered. Approximately 1 hour after the first dose of ondansetron, he was found unresponsive and in respiratory distress. Stat labs were ordered, and his blood glucose was 23 mg/dL. The patient had no history of diabetes or hypoglycemia. He was given glucagon and transferred to the intensive care unit. Laboratory studies showed an insulin level of greater than 1500 micro-units/mL (upper end of the reference range: 17 micro-units/mL). Intravenous glucose and glucagon were continued, and his blood glucose stayed in the low 40 mg/dL range for several days. Ultimately, he was discharged without any permanent disability from the event, but he was in a weakened state and his chemotherapy was delayed ("Workaround Error | AHRQ Patient Safety Network", 2019). The fact that the nurse had nine patients on a skilled nursing unit probably means that she was extremely busy and hurried and likely susceptible to unanticipated interruptions. When people are in a hurry or their concentration is broken repeatedly, they can easily mistake one item for another, or, when reading a label, not really see the words at all. Even under the best circumstances, there are limits on human thinking and the ability to be consistently accurate. The fact that a nurse can be given nine patients on a skilled nursing unit probably means that she can be extremely busy and hurried and likely susceptible to unanticipated interruptions. When people are in a hurry or their concentration is broken repeatedly, they can easily mistake one item for another, or, when reading a label, not really see the words at all. Even under the best circumstances, there are limits on human thinking and the ability to be consistently accurate. Thank you, Paola, for your response. I think it is unfortunate that they are nurses out there that are willing to take medication without counting them. Medication error is a huge problem for nurses, and they must follow the 7 rights in medication. But I understand that the nurse did not want to count the medication because she was busy at the time. Nonetheless, I think you did the right thing to report her for not recording the amount of medication because another nurse can get in trouble for discrepancies in the medication count. Another thing Paola is that the nurse that you were with did not take the time to write legibly when charting. This is surprising that the nurse did not take the time to write legibly because charting is the most important document that you have in any legal situation. In an article by the American Society of Registered Nurses stated in their article titled “Charting and Documentation”, that “Attorneys consider the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care” (Charting and Documentation, 2008). This means that as a nurse documenting in charting is arguably almost as important as nursing care itself. Unfortunately, charting does take time and when done on the computer it can be frustrating because of all the clicks and pathways. Sometimes computer networks can be slow and sometimes the computer itself can be very slow because it's old. But, Paola, if the nurse you were shadowing continues to use workarounds and shortcuts when charting, this will eventually catch up to her. For example, if she finds herself in court, she won’t be able to legally defend herself if she constantly does workarounds during charting. When there are issues with technology, instead of using workarounds we should be finding solutions to them. In our informatics textbook, in chapter 11 the author says “However, that improvement will be possible only if clinicians identify and report problems, rather than simply creating workarounds. That means that each clinician has a responsibility to participate in the design process and to report designs that do not work” (McGonigle & Mastrian, 2018). Paola after you reported your nurse to your teacher, hopefully, she will learn to suggest improvements instead of taking shortcuts. Also, this can be an opportunity for the nurse to learn time management skills and how to delegate tasks when they are busy. At the end of the day, there is never an excuse for workarounds because this puts you in legal jeopardy and your client’s life in jeopardy as well. Sources “Charting and Documentation.” (2008) Chronicle of Nursing. Nursing Journals: American Society of Registered Nurses, retrieved from www.asrn.org/journal-chronicle-nursing/341- charting-and-documentation.html. McGonigle, D. & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge. (4th edition). Burlington, MA: Jones and Bartlett. [Show More]

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