Adaptive behavior of clinicians in response to an over-constrained patient safety policy on the administration of concentrated potassium chloride solutions

Abstract

In response to fatal accidents involving concentrated potassium chloride (KCl) solutions, the Japanese hospital accreditation body released a safety policy in 2004 requiring the use of foolproof diluted KCl solutions throughout hospitals. However, the policy caused difficulties in treating seriously ill patients in critical care settings who require concentrated KCl solutions promptly. Resilient health care (RHC) provides a theoretical perspective for understanding how work is achieved in complex healthcare systems. ‘Work-as-imagined’ (WAI), as it should be done, and ‘work-as-done’ (WAD), as it actually takes place, are core concepts for understanding performance adjustment among individuals. This study aimed to investigate WAD regarding the administration of KCl solutions in the environment changed by WAI according to the authoritative policy.In 2017, we sent questionnaires to 346 critical care physicians. Topics included types of KCl products available in their units, administration methods, need for concentrated KCl solutions, hospital policies, and physician opinions. The response rate was 30.3% (105/346). Thirty-five physicians (33.3%) used conventional products out of compliance with the safety policy. Among 95 physicians using foolproof products, 69 (72.6%) obtained concentrated solutions from the products in an unsafe manner. The gap between WAI and WAD necessitated performance adjustments by physicians that introduced a new risk of adverse events despite the use of safer products.The study demonstrated that RHC theory can be used to inform the development and improvement of patient safety policies. Policy makers need to understand WAD when intervening in complex adaptive systems such as health care.