First- and Second-Order Problem Solving: When Rework and Workarounds Become an Opportunity for Improving Safety

Abstract

A newly employed ED charge nurse was approached by a laboratory worker who refused to draw necessary specimens because the patient was not wearing her identification wristband. This refusal was surprising to the charge nurse, because the patient had already received several urgent medications since arrival, and by policy, this process should have involved the use of a bedside bar code system for accurate patient and drug identification. It wasn’t initially clear to the charge nurse if the patient ever had a wristband placed, or if the wristband had been removed, but the charge nurse did confirm that an identification bracelet was not present. The charge nurse knew that it was a priority to get a new wristband before further treatment or medication administration, and because the patient’s nurse was not in immediate sight, she took steps to obtain a bracelet, confirm accuracy, and attach a new bracelet to the patient. 1 Institute for Safe Medication PracticesTaking steps to reduce tolerance to at-risk behaviors. ISMP Medication Saf Alert. 2008; 13: 2-3 Google Scholar Susan F. Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP ∗ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.