In a busy Med-Surg unit, a nurse searches for a stat medication, which is twenty minutes overdue for administration; unable to locate it, he orders a replacement dose and leaves the unit to retrieve it from pharmacy. A busy Oncology nurse retrieves symptom control medications from the automatic dispensing cabinet early, placing the dose in her pocket so that she doesn't have to return to the cabinet at a time when there are usually multiple nurses in line for medication access. Another nurse on a Transplant unit chooses a "basic infusion" mode, overriding an alert, because of discrepancies between the smart pump drug library and actual nursing practice workflow. All of these typical clinical scenarios provide insight into the care delivery challenges faced by nurses throughout our daily work, as well as the unintentional risk of harm these challenges may present as nurses attempt to work around them.
As the clinical provider responsible for the coordinated delivery of product and services to patients and their families, nurses are committed to providing the best possible patient care experience to our customers and our healthcare organizations. However, all too often we must spend valuable time addressing system breakdowns like those described above, and while unintentional, those efforts may compromise safety or efficiency. With the introduction of robust yet disparate technologies at the point of care, and shifting patient population characteristics that require complex coordination of care, exponential risks can also occur. Any unmet need or inefficiency in workflows, tools, processes, and interactions with other healthcare providers that emerges throughout the course of nursing care may present a potential for risk to productivity, patient safety, or both.
Shortcuts, omissions in steps, or ad hoc efforts employed by nurses to mitigate such breakdowns are typically developed with the intent to minimize the operational gaps, support the constant prioritization and re-prioritization efforts that occur throughout the course of a nurse's shift, or to maximize value-added time spent with our patients and their families.1 Such system shortcuts may be a reaction to "upstream errors" away from the bedside that are a function of improper or inefficient system design. Breakdown and related shortcuts are a reflection of low levels of inter-professional collaboration, and usually indicate a significant disconnect between clinical, operational, financial and/or supply chain organizations in attempting to address a critical need in patient care delivery. Other possible causes of the breakdown and shortcut cycle may include:
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