Back in July, I wrote a blog
about “alarm
fatigue.” In that blog I discussed my experience as a pediatric resident in
a Neonatal Intensive Care Unit with alarms that constantly went off. We had become
oblivious to them, unconsciously assuming that they were false alarms. In that
blog I also commented that in highly reliable high-risk systems, like in an
airplane cockpit, the alarms are minimized to those that are critical and that
in those systems everyone responds immediately to them.
This morning I was on our Lean Daily Management walk in the MICU.
Stacey Klingler, RN, the charge
nurse, was presenting the Board accompanied by her manager, Rachel Ridgely, RN. Stacey was in
mid-sentence explaining something to us when a patient alarm went off. Stacey
immediately stopped and started to move to the patient’s room as did Rachel. I
turned and looked towards the source of the alarm to see that other staff
members were on the move as well. A staff member gave a thumb’s up “all clear”
and everyone went back to what they were doing. Without missing a beat, Stacey finished
her explanation. I was so proud of
Stacey, Rachel and the entire team. If it is your loved one who is a
patient in our ICU, you don’t have to worry about an alarm being ignored.
We
thanked Stacey and Rachel for exhibiting the “preoccupation with failure” that
all high reliability teams exhibit and for not assuming that the alarm was false
or would be dealt with by someone else. Afterwards, I reflected on how quiet
the unit had seemed before the alarm went off even though the unit was very
full. We are making excellent progress in eliminating alarms that are not
helpful and in presuming that all alarms are real until proven otherwise.
Drift
Rachel
also told us that she was meeting with the leaders of our equipment hub. A few
years ago we created the hub to remove clutter (and eliminate blocked corridors
in the event of a fire) from our patient care units and also to have a system
where we always knew where our equipment was. This way it could be moved quickly
to where it was needed. At that time, we realized that hard-working,
well-intentioned physicians and nurses were hoarding equipment because they were afraid that they would not get
it back when they needed it…in other words, they knew that the system for
removing equipment from and returning it to the units was unreliable. Well, our system has worked pretty well since
we created it but Rachel was seeing some drift away from our standard work. The
physicians and nurses were beginning to hoard things again after one or two
episodes where they had called for things that could not be found.
It
is not a surprise that workers in unreliable systems begin to work around the
system. They are not doing it for malicious reasons. They do it because they
believe it will help them get their work done. But, as students of systems, we
need to point out that when a system starts to fail and people stop following
the design, it actually makes the system worse! Rachel is taking the
correct step to meet with the hub leaders and ensure that we continue to follow
our standard work to make sure that everything is in its place and moves
according to need.
What
do you think? Do you see other examples of drift away from standard work?
Please comment below.
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