CURRY COLLEGE
Nursing Department
Workarounds
As Identified By
Senior Preceptored Students
QSEN Conference
June 22 – 25, 2008
Charlotte, NC
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CURRY COLLEGE
Nursing Department
Project Team
• Elizabeth C. Kudzma, DNSc, MPH, WHNP-BC
• Maureen L. Murphy, PhD, EdM, CNM
• Cathleen C. Santos, MSN, RN
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CURRY COLLEGE
Nursing Department
Curry College: QSEN Strategies
1: Ask faculty to add “level of evidence” on all
PowerPoint slides illustrating clinical studies
application in classroom teaching (EBP).
2: Develop a modified PowerPoint presentation of
When Things Go Wrong: Responding to Adverse
Events to integrate into several nursing courses
(S, QI).
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CURRY COLLEGE
Nursing Department
3: Adopt prepared institutional (BIDMC) resources,
such as adverse event flow sheets, as teaching tools
in selected nursing courses (S, QI).
4: Design and use student cards/tags for medication
rights, SBAR, Rapid Response Team triggers (S).
5: Designate one clinical conference on quality
improvement projects in the assigned care setting in
each clinical rotation (QI).
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CURRY COLLEGE
Nursing Department
6: Revise the Critical Objectives for Clinical Evaluation
adapting an institutional systems focus with the
assistance of the practice partner (S, PCC).
7: Develop clinical assignments to assist students in
identification of potential unsafe nursing practices
including “work arounds”(S).
8: Involve the student in quality assurance projects (or
committees) as part of precepted clinical practicum
with the practice partner (QI).
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CURRY COLLEGE
Nursing Department
9: Participate in a Root Cause Analysis experience
with the practice partner in selected nursing courses
(QI, S).
10: Purchase First, Do No Harm Parts 1, 2, 3
(Safety, QI, PCC)
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CURRY COLLEGE
Nursing Department
Strategy # 7
Develop clinical assignments to assist
students in the identification of
potentially unsafe nursing practices
including workarounds (WA).
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CURRY COLLEGE
Nursing Department
AHRQ Glossary:
Workarounds: From the perspective of frontline
personnel trying to accomplish their work, the design of
equipment or the policies governing work tasks can
seem counterproductive. When frontline personnel
adopt consistent patterns of work or ways of bypassing
safety features of medical equipment, these patterns
and actions are referred to as “workarounds.” Although
workarounds “fix the problem,” the system remains
unaltered and thus continues to present potential
safety hazards for future patients.
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CURRY COLLEGE
Nursing Department
 Faculty and Students
 Clinical Organization to Point of Care
 Introduced:
When Things Go Wrong
Adverse Events Reporting
Root Cause Analysis
Fair and Just Culture
Workarounds
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CURRY COLLEGE
Nursing Department
Faculty Assessment
QSEN Workaround Questionnaire:
1. Are you familiar with the term “workaround”
2. Have you discussed workarounds with your students
3. Would you be able to identify workarounds
4. Please list 3 examples of workarounds
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CURRY COLLEGE
Nursing Department
Faculty Assessment Outcomes
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Office phone limited access – uses personal cell
Cold classrooms – faculty/students wear layers
Scheduling classrooms – several administrators
Classroom vs. # of students – pulling in desks/chairs
Late withdrawals – calls Registrar directing
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CURRY COLLEGE
Nursing Department
Faculty Challenges
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Unfamiliar with quality and safety language
Some not currently in active practice
First-order problem solving viewed as innovative
Second-order problem solving viewed as time
consuming
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CURRY COLLEGE
Nursing Department
Faculty Project Activities
• Faculty Educational Retreats:
October 26, 2007
February 02, 2008
May 15, 2008
Patricia Folcarelli, PhD, RN
Director of Professional Practice
Beth Israel Deaconess Medical Center (BIDMC)
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CURRY COLLEGE
Nursing Department
Educational Retreat Content 10-02-07
• Patient Safety Series Film: “When Things Go Wrong:
Voices of Patients and Families”
• Swiss cheese model (Reason, 1991)
• Blunt end and sharp end
• Hindsight bias
• High reliability organizations
• Culture of safety
• Person vs. systems paradigm - Workarounds
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CURRY COLLEGE
Nursing Department
Educational Retreat Content 02-02-08
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Error Classification Systems
Sentinel Events, Close calls/near misses
Accountability Determination Model
Root Cause Analysis (RCA)
RCA systematic and thorough-look everywhere
Team Structure and Climate
Supporting the second victim, frequently the nurse
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CURRY COLLEGE
Nursing Department
Educational Retreat Content 05-08-08
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Adverse Event Reporting
Fair and Just Culture (James Reason, 1997)
Fair and Just Decisions on Individual Accountability
National Quality Forum – “Never Events”
Communicating in the Aftermath of an Adverse Event
Process for Reporting and Analyses - Adverse Event
Transparency - Adverse Event
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CURRY COLLEGE
Nursing Department
• Dedicated QSEN intranet access for all faculty
• QSEN - standing department agenda item
• > 50% faculty attended multidisciplinary QI/RCA
clinical conferences hosted by BIDMC
• Developed an appreciation for Transparency
• Revised Critical Objectives for Clinical Evaluation
• Tucker, A. L. and Edmondson, A. C. (2003).
Why hospitals don’t learn from failures: Organizational
and psychological dynamics that inhibit system change.
California Management Review, 45 (2), 55-71.
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CURRY COLLEGE
Nursing Department
"Patient Safety and Health System Reform"
Lucian L. Leape, M.D.
Curry College
Keith Auditorium
September 23, 2008
4:30 p.m. – 5:45 p.m.
Reception to follow in the Parents’ Lounge
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CURRY COLLEGE
Nursing Department
Senior Precepted Student Assessment
QSEN Workaround Questionnaire:
1.
2.
3.
4.
AHRQ Glossary of Safety and Quality-Related Terms
Have you discussed workarounds with your preceptor
Were you able to identify any occurring on your unit
Please list 3 examples of workarounds
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CURRY COLLEGE
Nursing Department
Senior Precepted - Assessment Outcomes
Identified Workarounds:
• Equipment
• Personnel - Nursing Staff
• Medication Administration
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CURRY COLLEGE
Nursing Department
Senior Precepted - Assessment Outcomes
Equipment:
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Silencing alarms w/o investigation
Failure to turn on bed alarm
Overriding IV infusion pump drug – rates
Using another’s ID to scan the use of glucometers
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CURRY COLLEGE
Nursing Department
Senior Precepted - Assessment Outcomes
Personnel – Nursing Staff:
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Lack signage to indicate precautions
Failure to observe precautions
Failure to round q 2 hours to check restraints
Hourly checks not performed but documented
Failure to confirm code cart security
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CURRY COLLEGE
Nursing Department
Senior Precepted - Assessment Outcomes
Medication Administration
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Orders verified to best suit needs of nurse
Failure to use Pyxis system as intended
Withdrawing medication prior rating pain level
Failure to confirm patient ID against MAR
Leaving medications at bedside
Failure to calculate/witness narcotic waste
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CURRY COLLEGE
Nursing Department
Senior Precepted Student Challenges
• Preceptors not familiar with term “workarounds”
• One student viewed workaround as commendable
• Conflict noted between optimal/actual clinical
nursing behaviors
• May not recognize a workaround: trusted preceptor
was demonstrating proper nursing practice
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CURRY COLLEGE
Nursing Department
Senior Precepted Student Project Activities
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Blackboard: “QSEN Corner” Student resource
PowerPoint /Lecture/ Blackboard Documents
Interactive classroom RCA exercises
BIDMC access to multidisciplinary QI/RCA meetings
Exposure/appreciation for the concept of Transparency
AHRQ Glossary of Safety and Quality-Related Terms
Senior externship seminar discussions re: WA
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CURRY COLLEGE
Nursing Department
Senior Precepted Student Project Activities
• Clinical Response Sheets:
 When Things Go Wrong – PowerPoint
 Quality Improvement – clinical setting
 Workarounds – identify
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CURRY COLLEGE
Nursing Department
Teaching/Learning Strategies
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AHRQ glossary
Tucker, A. L. and Edmondson, A. C. (2003).
Seminar/Clinical discussions
Clinical preparation sheets - identify WA
Continue QSEN efforts with BIDMC
Duplicate QSEN efforts with other agencies
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CURRY COLLEGE
Nursing Department
Teaching/Learning Strategies
• ID first-order practice WA
• ID second-order practice WA
• Compare to practice guidelines
• ID first-order organizational WA
• ID second-order organizational WA
• Contribute to organizational culture change
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CURRY COLLEGE
Nursing Department
Curricular Changes
Initiate early introduction to :
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Workarounds
Fair and Just Culture
Root Cause Analysis
Adverse Events Reporting
When Things Go Wrong
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CURRY COLLEGE
Nursing Department
Sustainability
• REVISED:
Critical Objectives for
Clinical Evaluations (5/08)
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Adult Health I
Maternal-Newborn
Advanced Med-Surg
Capstone Synthesis
Preceptored Clinical
NSG 2041
NSG 2051
NSG 3050
NSG 3982:
NSG 3983:
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Sophomore
Junior
Senior
Senior
Senior
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CURRY COLLEGE
Nursing Department
To Lobby is Legal:
“Most Effective Clinical Partnership”
3 Onsite Faculty Retreats presented by BIDMC
Access to BIDMC multidisciplinary QI/RCA meetings
“We Hit the Home Run”
Lucian L. Leape – guest speaker
Harvard School of Public Health
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