[two_third]<\/p>\n
One of the sessions I attended at the Institute for Healthcare Improvement\u2019s conference in early December really got me thinking. I enjoy it when I\u2019m challenged on assumptions or my usual approach to doing things, and am given something new to think about. I registered for this session because, perhaps like many of us who have been working on improving safety, I had been feeling stuck. The speaker was Carol Haraden, PhD, a Vice President at the IHI, and I\u2019ll summarize what I took away from her talk \u2013 this blog may not represent literally what she said, but it\u2019s what I learned.<\/p>\n
A concept Carol presented that opened my eyes is what I\u2019ll call \u201csafety creep\u201d although its official name is \u201cSystem Migration to Boundaries.\u201d First, there is a right way of doing things: this is an expected \u2018safe space\u2019 of action defined by professional standards. For example, two nurses check each unit of blood before administering it, and one checks the patient\u2019s ID band: this is the safe space of action.<\/p>\n
Over time the behavior starts to creep over to the \u201cillegal but normal\u201d real life standards, aka usual way of doing things: when we\u2019re busy, we still have two nurses check the bag, but it\u2019s ok not to check the ID band (we know who are our patients are, right?).<\/p>\n
Creep continues into the \u2018illegal illegal\u2019 or very unsafe space, with increasing chance of accidents. For example, now we don\u2019t find a second nurse to check the bag, nor do we check the ID band. Most of us would call that \u2018an accident waiting to happen.\u2019 These are the circumstances where, when something bad happens, anyone can say in retrospect, \u201cWhy did they keep doing that? Didn\u2019t everyone see how unsafe it was?\u201d<\/p>\n
One reason for erosion in safe practices is that as new staff enter this work environment, they are oriented not to the \u2018safe space\u2019 or right way of doing things, but to the \u2018illegal but normal\u2019 standards that are the practice in that setting. Thus they perceive these standards as the safe space of action, when in fact they are illegal but normal. Unless we continually work to move back to the expected safe space from the usual space, and orient\/train to the safe space, we are allowing safety to degrade.<\/p>\n
Best wishes for a safe and happy new year.<\/p>\n