Monday, January 3, 2011

Red Queen's Race

Alice in Wonderland the Red Queen’s Race

Alice is constantly running but remaining in the same place. In Wonderland, running a race does not actually get you anywhere. As the Queen explains to Alice, “Here it takes all the running we can do to stay in the same place. If you want to go somewhere, you must run at least twice as fast.”

Where we are in healthcare reminds me of the Red Queen’s Race. It seems as if we are always in a race against time. Last week when I was listening to the webinar, “Is Your Culture Ready for Event Reporting?” one of the panelists made this comment, “Everything we do is to try and optimize our time.” When you think about it our expertise and time is what we have to give to our patients.

In the hospital how we cope with our race against time, creates an unsafe environment. This happens for several reasons; decreasing resources, increasing demand, sicker patients, and a complex system with poor design. There is pressure to move patient’s through the hospital as “quickly” as possible, while trying to do it safely and keep costs down.

When we speed things up, and do not improve our system, there is an increased chance for errors. We only have so much time to get our information and make a decision. Our communications paths are weak and information moves slowly. How fast can we make our decisions and still provide error free care?

The faster we run, the more confusion there is. When things are not clear, we do the best we can and make decisions based on what we know at that time, creating rework, duplication, wasted time, and errors. If we acknowledge that we are confused, this can preclude an error.

When we are running the race, it is hard to “STOP” and make sure we are on the right path, and have clear communication on what we need to say or do. How many times when we are driving and in a hurry to get somewhere, do we take a wrong turn and it actually takes us longer than if we were able to slow down and think about where we were.

Here is a recent example of what happened to Mary RN, a new nurse in orientation on a Pediatric Unit

Mary had three more shifts of orientation left on nights when her preceptor called in sick. The unit had been working short staffed lately, so it was decided not to call in another nurse to be her preceptor, and that Mary would be on her own. To make sure she would be OK doing this, she was told to ask any of the nurses if she had questions.

The charge nurse thought that Mary was competent enough to handle this assignment, especially if the other nurses could help her if needed. Also, Mary had worked on this unit 3 years ago. However, since that time, the staff had changed, and this was a new building with a different patient population. Mary was somewhat uneasy about this but accepted the assignment because she did not want to create any extra stress on the staff.

Her patient had a pain pump and there were doctor’s orders from the previous day to turn off the medication pump and start oral medications 0600. Mary had never seen this type of order and was not clear about what to do. She wanted to make sure she had it correct, so she asked the charge nurse who did not have time to help her. So then, she had to find another nurse to ask. Mary explained what she thought the order said and this nurse quickly looked at the orders and said, "yes that’s right.”

At 0600, Mary went into the patient’s room and turned off the pump and removed the administration catheter. Around 0830 the patient felt a rapid withdrawal from the pain medicine and was in 10/10 pain. Morphine had to be given almost every 10minutes for an hour to manage the patient’s pain level and it was not well controlled until 1400.

Mary did not have the order correct, she was to only turn off the pump, not remove the catheter and then start the oral pain medications right away. Mary thought that was oral medication was ordered for later in the day. The nurse Mary asked was running around and very busy so she did not take the time to go through all the orders to make sure everything was correct.

When Mary came back onto shift the next night, she had heard what had happened and felt very angry and became unconfident in herself. This was all because no one took the time to “STOP” and look over the orders, then go through them step by step with Mary.

This was an adverse event and as a result, the patient suffered extreme pain that was not easy to manage. This also put the patient was at risk for other harmful side effects from this error. In addition, consider how many people and how much time it took for this one activity.

We have been running for the past 10 years trying to improve patient safety and have failed miserably. We have been in the race but staying in the same place and even going backwards.

Somehow, we need to “STOP” the race and see where we are going. We need to create a NEW PATH, without this we will never make the finish line and keep our patients safe.

The GOOD news is:

We have started to “STOP” running and look at:

Where we are

Where we are going and

How we are going to get there.

Once we do that in Healthcare, we need to organize a NEW RACE and
run twice as fast for IMPROVEMENT.