Abstract
Addressing microsystem problems from the frontline holds promise for quality enhancement. Frontline providers are urged to apply quality improvement; yet no systematic approach to problem detection has been tested. This study investigated a self-report approach to detecting operational failures encountered during patient care. Methods. Data were collected from 5 medical-surgical units over 4 weeks. Unit staff documented operational failures on a small distinctive Pocket Card. Frequency distributions for the operational failures in each category were calculated for each hospital overall and disaggregated by shift. Rate of operational failures on each unit was also calculated. Results. A total of 160 nurses participated in this study reporting a total of 2,391 operational failures over 429 shifts. Mean number of problems per shift varied from 4.0 to 8.5 problems with equipment/supply problems being the most commonly reported category. Conclusions. Operational failures are common on medical-surgical clinical units. It is feasible for unit staff to record these failures in real time. Many types of failures were recognized by frontline staff. This study provides preliminary evidence that the Pocket Card is a feasible approach to detecting operational failures in real time. Continued research on methodologies to investigate the impact of operational failures is warranted.
Highlights
Nurses are the largest sector of the healthcare workforce and, as such, constitute most of what human factors experts call the “sharp end” of the healthcare system, the segment in direct contact with patients
Hospital B was a 400+ beds, not-for-profit agency recognized by the American Nurses Credentialing Center as a Magnet facility [13] and had implemented the Transforming Care at the Bedside (TCAB) program [14,15,16]
Debriefing interviews with them at study conclusion did, suggest that they found the frontline perspective meaningful and a potential guide for action. The results of this exploratory study suggest that small operational failures are common on medical-surgical clinical units and it is feasible for unit staff to record these failures in real time
Summary
Nurses are the largest sector of the healthcare workforce and, as such, constitute most of what human factors experts call the “sharp end” of the healthcare system, the segment in direct contact with patients. This is especially true in hospitals, the sharpest, most hazardous, site of patient care [1], where 63.2% of nurses (2.8 million RNs) were employed in 2010 [2]. Most adverse events in healthcare originate from small process failures that are common enough to be taken for granted [6, 7]. Problems occur about once per hour per nurse on hospital units, and 95% of problems are managed through workarounds (alternate ways to achieve a goal) rather than system corrections [8, 9]
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