Safety: What Went Right—What Went Wrong

Continued from page 7

In an example of a workaround leading to an improved process, the “brief operative note” necessary in the Post-Anesthesia Care Unit (PACU), and the completed formal operative note for the same routine procedure were combined into one document. With the use of electronic health record capabilities, both the brief and the formal operative notes could be completed and available when the patient arrived in the PACU. This provided all the necessary and required information in an easy-to-read format and completed procedural documentation requirements more quickly than previous processes while eliminating duplication of documentation elements. However, initially this workaround conflicted with organizational policy which described two required documents. To the organization’s credit, the value of the workaround was appreciated, and policies were changed to legitimize this improved process. the patient safety implications of this situation are clear. However, this example also speaks to the missed opportunity to improve the systemic process by which pharmacy was delivering medications to inpatients.

Healthcare technology workarounds are plentiful and also can create hazards. In response to complex login passwords, users may post their password alongside their computer, leading to the potential for a significant data breach. In response to IV pumps with built in “smart technology” which malfunctions or is difficult to program, care teams may bypass the ostensible safety features instead of improving the programming or reporting the malfunction.

In all of these situations, workarounds are a way to accomplish work when “work as done” does not achieve the efficiency or functionality of “work as imagined” for designed processes. However, continuing to use a workaround camouflages problematic processes. If leadership is unaware of shortcomings, they won’t allocate resources to fix the problems.

Agreement

Workarounds should be viewed as learning opportunities. In one workaround analysis, it was discovered that nurses were unable to use the mandated barcode medication administration system correctly because of a lack of internet connectivity in some patient care areas.11 No amount of “retraining” the nurses would have corrected that underlying problem but studying the workaround and identifying and mitigating a technologic limitation contributed to a more effective remedy. Some workarounds bring to light system shortcomings, others provide potential system improvements. Simulations that replicate patient care processes,12 and interviews conducted with respect for local expertise are among the methods that can be used to discover, develop, and test system improvements. Crucially, the surfacing and studying of workarounds can provide valuable information about how to improve patient care processes.

References:

1. Merriam-Webster. (n.d.). Life hack. In Merriam-Webster.com dictionary. Accessed 4 October 2021, from https://www.merriam-webster.com/dictionary/life%20hack 2. Deutsch ES. Workarounds: Trash or Treasure? Pa Patient Saf Advis 2017 Sep;14(3). 3. Brous E. Crisis Standards of Care. Am J Nurs 2021 Jul 1;121(7):51-54. doi: 10.1097/01.NAJ.0000758504.14938.01. 4. Hallal A, Andraos R, Saad GA, Boyajian T, Hoballah J. Mass casualty management during a pandemic surge: The American University of Beirut Medical Center experience. Semin Vasc Surg. 2021 Jun;34(2):51-59. PMID: 34144748 doi: 10.1053/j.semvascsurg.2021.04.005. Epub 2021 May 25. 5. Vincent C, Amalberti R. Safer Healthcare: Strategies for the Real World. 2016. New York, NY: SpringerOpen 6. Chuang S, Woods DD, Ting Hsieh-Wei. Cook RI, Hsu J-C. Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust

Explosion. Disaster Med Public Health Prep. 2020 Aug;14(4):467-476. PMID: 31439072 doi: 10.1017/dmp.2019.69. Epub 2019 Aug 23. 7. Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Quality & safety in health care. 2005;14:130-4. 8. Tucker AL. Workarounds and resiliency on the front lines of health care. Rockville (MD): Agency for Healthcare Research and Quality; 2009 Aug. 6 p. 9. Top 10 Patient Safety Concerns for Healthcare Organizations 2018. https://www.ecri.org/EmailResources/PSRQ/Top10/2018_PSTop10_ExecutiveBrief.pdf accessed 4 October2021. 10. Brown T. The American Medical System is One Giant Workaround. https://www.nytimes.com/2019/09/05/opinion/hospital-workaround-health-care.html accessed 4 October2021 11. Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. Near-Miss Event Analysis Enhances the Barcode Medication Administration Process. Pa Patient Saf Advis 2017

Dec;14(4). 12. Stone K. Exploring Workarounds: The Role of Simulation to Build Resilience. In Comprehensive Healthcare Simulation: Improving Healthcare Systems. Eds: Deutsch ES, Perry SJ, Gurnaney

HG. Springer 2021

Evaluation of Water Absorbent Polymer Beads as a Head and Neck Foreign Body in Children

Harleen Sethi, DO; Brigitte Wilkens; Pamela Roehm, MD, PhD

Superabsorbent polymer (SAP) beads were developed for agricultural use for the purposes of water retention in soil and their use has subsequently been diversified. Since the advent of their use in children’s toys, including sensory tables for children, SAP beads have been identified as potential ingested and inhaled foreign bodies. Two case reports have identified these objects as external auditory canal foreign bodies. Following removal of SAP beads from 3 patients within the past year in the Pediatric Otolaryngology clinic, we studied the physical characteristics of these foreign bodies and compared these measurements to sizes of the external auditory canal and nasal airway in children and adults.

Physical changes in SAP bead dimensions were measured through time in Photoshop after a) saturating bead with water or b) after withdrawal of bead from water. All measurements were duplicated in 3-6 beads through multiple trials of beads which had been sorted by coloration (clear, pink, or purple). Unhydrated SAP beads (Orbeez) were hydrated with water. Measurements of bead size were performed at regular timed intervals

Figure 1. Hydration of SAP beads

Bead sizes increased dramatically after hydration. Beads shown prior to addition to water (0’), at 6 hours (360’) and at 24 hours (1440’) after hydration. Bead sizes plateaued at 360 minutes

Figure 2. Time Course of Hydration

Plot of average bead diameter after hydration. Bead sizes plateaued at 360 minutes.

following hydration. Maximum size of hydrated beads was significantly larger for pink and clear v. purple beads. Maximum hydrated sizes of all beads were significantly larger than average adult external auditory canal width (0.24-0.92 cm) and the average adult nasal cavity width (0.3-0.7 cm).

Fully hydrated beads were removed from water and bead size was measured at regular timed intervals. Plot shows average bead diameter over all repetitions. Bead sizes began to significantly decrease at 6 hours and arrived at dehydrated widths at 24 hours.

Figure 3. Dehydration of SAP Beads

In our study, SAP beads rapidly increase in size in solution reaching sizes larger than the average adult external auditory canal width (0.24-0.92 cm) and larger than most adult nasal airway widths (inferior turbinate to nasal septum, = 0.30.7 cm) within minutes of hydration. SAP beads decrease in size very gradually over time after removal from hydrating fluids. Review of the medical literature revealed 3 patients who had SAP bead foreign bodies in the head and neck, all within the ear. All patients had resulting tympanic membrane perforations and 2 had ossicular erosion and one had profound hearing loss and profound auditory and vestibular loss due to otic capsule erosion from the SAP bead. The damage to otologic structures was attributed to attempted removal with irrigation and otologic drops. Thus, removal of these expansile objects in the head and neck should be performed in an expedited fashion with blunt instrumentation or suction rather than with irrigation.

References

1.Sterling, M., Murnick, J., & Mudd, P. (2016). Destructive Otologic foreign body: dangers of the expanding bead.

JAMA Otolaryngology–Head & Neck

Surgery, 142(9), 919-920. 2. Ramgopal, S., Ramprasad, V. H.,

Manole, M. D., & Maguire, R. C. (2019). Expansile superabsorbent polymer ball foreign body in the ear.

The Journal of emergency medicine, 56(6), e115-e117.