Cleaning up puddles & addressing the workaround

In the morning our safety moment consisted of Dr. Mayer speaking about mindfulness vs. mindfulness and action. In a grocery store, Dr. Mayer noticed a puddle. He pointed out the puddle to his good friend, Cliff, and continued walking. Meanwhile, his Cliff noted the puddle, found a manager, and ensured the issue was addressed and resolved so that no adverse outcomes would result. This safety moment reminded me of the conversation I had with my small group during the domino game on Monday. We spoke of the danger of workarounds, which, in the hospital setting, is the equivalent of noticing. Puddle and walking around it (sorry Dr. Mayer!)

A workaround I have frequently encountered is the malfunction of the emar system at the bedside. Either 1. The computer is running too slow to realistically accommodate the morning med pass 2. The scanner is broken or 3. The bar code on the medication itself will not scan. When these issues arise, the rush of the AM medication administration, patient assessment, and rounds, often necessitate having to go find a portable scanning station to bring into the room. Should I call IT to resolve these technical difficulties? Should I call pharmacy to reprint the med label? Yes to both. Do I? Often times, no. I feel as though I don’t have the time. Why is walking around the puddle an issue? Patients could potentially receive the wrong dose, ie: lopressor #50 vs lopressor #25 ( the computer prompting me to halve the pill) or worse- the patient the patient receiving the wrong medication all together.¬†Thankfully, I have not come into contact with such an issue, and when I find a lull in the day, I will take steps to ensure the underlying issue is resolved. Our Tuesday morning safety moment brought up a common issue many of us have faced in the clinical setting. How do we decrease the incidence of workarounds? What workarounds to my fellow nurses and doctors encounter most frequently in their respective clinical settings?

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