It’s Just Common Sense
July/August 2011
Editor’s Notebook
It’s Just Common Sense
I recently moderated a webinar about a problem in healthcare that hadn’t occurred to me—nor to many others, it appears—but seems quite obvious now that it’s been brought to my attention. In the webinar, Dennis Tribble, chief pharmacy officer at Baxa Corporation, joined Stuart Levine of ISMP and Denise LaStoria, owner of Training Advantages, LLC, to discuss problems inherent in train-the-trainer programs used for technology training, especially in the pharmacy. (The webinar took place on June 25, 2011, and is available at www.baxa.com/webinars.)
When he first described the problem to me, Tribble used the old parlor game sometimes called telephone as a metaphor. To play the game, one person whispers a sentence or two in someone’s ear, that person whispers the same to another person, that person passes it along, and so on. When the person at the end of the line repeats the sentence out loud, it may only loosely resemble the original statement. Without intending to, each person along the way is likely to have modified the sentence, with amusing results. When this happens with training for medical technology, it causes real problems. This effect is sometimes referred to as “drift”—another mild-sounding metaphor for something that should be of real concern.
The reasons for drift may seem obvious and innocuous, but in fact, there are important forces at work. Some drift happens inadvertently, accelerated perhaps by staff turnover. Sometimes, drift is purposefully introduced by individuals who believe they know a better way to accomplish the task at hand—often called “workarounds.” As became clear during the webinar, this problem shares root causes with most other safety problems in healthcare: system deficiencies, poor communications, ineffective leadership, and—most interesting to me at this moment—our failure to see the obvious.
Why is it so hard for us to see what’s plainly in sight? Or, to say that another way, why is it that we seem so often to leave our common sense at the door in healthcare? Doesn’t it seem obvious that competence for using medical technology should not be entrusted solely to a grassroots process? The advantages of using in-house super trainers—chiefly efficiency of time and money—are undeniable, but should not be left unexamined. Common sense should remind us not to assume that the original training will persist unchanged and that it should be reinforced and evaluated continually.
It’s easy to think of other patient safety problems that seem self-evident, now that we’ve recognized them at long last. How did we miss for so long the fact that men and women who feel emotionally or physically threatened by their co-workers cannot be expected to perform at their best? How did we ever think it was a good idea to allow clinicians who have inadvertently harmed or even killed a patient to move on to the next patient without emotional support? What advantage do we see in denying patients access to their own medical data?
There are some reasonable answers to those questions and tremendously complicated forces—including increasingly difficult financial dynamics—at work in healthcare delivery. Common sense alone will rarely be a sufficient solution. With our webinar on train-the-trainer programs, however, I’m reminded that common sense, clear vision, and simple questions, which ironically may seem “out of the box,” can lead to important discoveries.