Issue link: https://digital.copcomm.com/i/1130164
18 Working Nurse l WorkingNurse.com June 10–July 15, 2019 15 Workarounds and 31 Causes I ronically, during this same time in my career, I was also researching shortcuts and workarounds in medication administration for my second book, Successful Nurse Communication, published in 2015. At the time, medication scanning was just becoming popular in hos- pitals, but patient safety issues persisted — as they still do. Between 2003 and 2006, during the early days of barcoded medica- tion administration (BCMA), health IT expert Ross Koppel, Ph.D., FACMI, and his colleagues observed and shadowed nurses using BCMA systems at five hospitals. Their study, published in The Journal of the American Medical Informatics Association in 2008, identified 15 different types of BCMA workarounds, ranging from affixing patient identification barcodes to door jambs, computer carts, or nurses' belt rings to carrying several patients' pre-scanned medications on carts. The authors identified 31 probable causes for such workarounds. Some were mechanical, including equipment-related problems (such as dead batteries, connectivity issues or scanner failure); unreadable or missing barcodes or patient identification bands; or specific medica- tions not being correctly catalogued. Others included the kinds of problems I had experienced, such as nurses being too busy or too distracted to follow the proper protocols, which didn't always fit the nurses' normal workflow. It seems we are pretty creative about bending the rules to get things done. Unfortunately, that creativity can have deadly consequences. Lessons from the Challenger Disaster I t is one thing to cut corners on rare occasions, particularly if it's due to emergency or equipment failure. In those situations, we might not have any real alternative. However, when we cut corners repeatedly, those shortcuts become bad habits. As I related in the opening story, I made it a habit to pre-pour meds whenever we were short-staffed or if something else caused me to fall behind. I rationalized that it was the only way to get people their medications on schedule, or at least close to it. I don't think many nurses could honestly claim they've never once bent the rules. In many cases, nothing really comes of it. The problem is that bad habits like these lead to what Columbia University sociologist Diane Vaughan, Ph.D., has dubbed "the normal- ization of deviance." She coined this term in her analysis of the explo- sion that destroyed the space shuttle Challenger in 1986. Normalization of deviance describes the natural human tendency to do something the wrong way under pressure and then make a habit of it because it hasn't yet resulted in any significant consequences. After a while, that bad habit becomes the new normal. Instead of correcting it, we start adding more bad habits on top of the original one, setting aside yet more proper protocols and safety precautions. Eventually, something bad does happen. Talking about the Challenger disaster in a recent YouTube video, former astronaut Mike Mullane explained that because of the normal- ization of deviance, that devastating tragedy "was not an accident. It was a predictable surprise." HAZARDOUS HABITS The problem is that bad habits lead to what Columbia University sociologist Diane Vaughan, Ph.D., has dubbed "the normalization of deviance."