The Risk of Workarounds

In April, Patient Safety and Quality Healthcare published an article summarizing a recent webinar presented through our Center for Safety and Clinical Excellence. The article is titled “Smart Pump Workarounds – What’s the Legal Risk?”, and it focuses on personal accountability on the part of caregivers in safely operating Smart IV pumps.

Caregiver accountability has been a hot topic in recent months. As it relates to IV medication safety, it’s a critical issue and worth paying attention to. It’s been shown that clinicians often implement process workarounds, including not utilizing the drug library, overriding soft dose and concentration alerts, reprogramming infusions as rate in ml/hr following hard limits, and occasionally removing IV tubing from pumps and delivering medication boluses by gravity to avoid a high dose alert.  Although no formal study to date has explored the reasons for non-compliance, there are many potential contributing factors, including time, the belief among some caregivers that they do not make mistakes, alert settings that may not be consistent with current medication practices, and administration practices that are outside established hospital policies.

Regardless of the reasons why, it’s become clear that compliant use of medication safety technologies varies within and between hospitals. But, when you combine high-risk IV medications and the frequency of programming errors, anything less than full compliance is a patient safety risk.  Lately, there’s been an increased focus on the “second victim” of medical errors—the clinician. In an earlier webinar and a recent Perspectives blog, we discussed the case of Eric Cropp, a pharmacist who served jail time after missing a medication error that ultimately took the life of two-year-old Emily Jerry. Eric did not have access to a technology solution that could have helped identify and prevent the compounding error. But in cases where caregivers have a choice and choose to work around best practice and compliance guidelines, the concept of the second victim takes on a whole new meaning.

This topic brought me back to a familiar line from Hill Street Blues—one of my all-time favorite TV series. Based on a New York Police department, each show began with Michael Conrad reminding his police force, “Let’s be careful out there!” Great advice for all of us.