DDHA 8103 Week 1 Harm Despite Controls Post Example

Week 1 Discussion: Why Harm Persists in Controlled Systems

Controls Built Against the Last Burn: Why Harm Got Through a Rehabilitation Network Whose Checks All Worked

Hello, everyone. I direct quality for the outpatient rehabilitation division of a regional system I will call Hollins Ford Health, a composite of twelve physical therapy clinics. My example this week is small, and that is the point. Last spring a 74-year-old patient with type 2 diabetes received a moist hot pack on his lower back and went home with a partial-thickness burn about the size of a postcard. Every control we had on paper was in place that afternoon. The heating unit's temperature log was complete, the intake form asked about numbness, the pack was wrapped in the required towel layers and an aide documented a skin check at five minutes. None of those steps failed in the sense of being skipped.

Each control rested on an assumption. The sensation question assumed that a patient who reports numbness only in his feet has normal feeling across his back. The five-minute check assumed that the patient's own report of comfortable warmth tracks what is happening in the skin. Most important, the towel standard assumed the pack sits on top of the patient. In this case he lay on his back with the pack beneath him, because lying face down hurt his shoulder. Body weight presses the towels flat, squeezes out the insulating air and slows the blood flow that normally carries heat away. The layers were counted correctly and no longer did their job.

That positioning was not a one-off lapse. Lying on the pack with an extra towel had become routine in several of our clinics, a quiet adjustment for patients who could not tolerate lying prone. Reason (2000) describes how latent conditions sit inside a system until an ordinary act lines up with them, and Banja (2010) explains how a shortcut that produces no visible harm gets accepted step by step until nobody sees it as a deviation at all.

Here is the claim I would like you to test. Our audit program cannot see this kind of drift until long after it is adopted. Our quarterly chart audit asks whether the five-minute check was documented, and it was, every time. Positioning is not recorded anywhere, so the audit kept reporting full compliance while the practice it was meant to protect had changed underneath it. I would estimate that the workaround was in use for well over a year before this burn, and I think that lag is the normal case rather than the exception.

I should grant the opposite case. Some controls do catch drift early, and they share a feature: they observe the work itself rather than the record of it. A supervisor who walks the treatment area at random times would have seen patients lying on packs. Our controls were built to answer the question raised by the last burn the division had, years ago, which was an undocumented skin check. They were not built to notice a new way of being harmed.

Reply to Renee

Renee, you argue that frontline reporting should have surfaced the practice, since staff report near misses in your hospital within days. I agree that reporting works when staff recognize an event as an event. My difficulty is that redness after moist heat is expected, so a patient with pink skin after lying on a pack was never a near miss in anyone's mind. Shojania (2008) points out that incident reporting captures a small and skewed share of harm, weighted toward events staff already consider reportable. If the deviation has become normal, the reports will not come, and the gap between adoption and detection stays long. Would your hospital's reporting have caught a practice that everyone considered good patient care?

Reply to Marcus

Marcus, you ask what observation would separate a harmful workaround from an adaptation that improves the work. That is the right question, because Debono et al. (2013) found that workarounds often exist for sound reasons and sometimes protect patients. My working test has two parts. First, does the adaptation replace the protection it bypasses with something equivalent? An extra towel replaced none of what body weight removed, so it failed. Second, is the adaptation visible to the people responsible for the process? Ours lived in no policy and no record. Amalberti et al. (2006) describe this migration of practice toward the boundary of safety under pressure. An adaptation that passes both tests can be written into the procedure. One that fails either should be treated as an exposure.

References

Amalberti, R., Vincent, C., Auroy, Y., & de Saint Maurice, G. (2006). Violations and migrations in health care: A framework for understanding and management. Quality and Safety in Health Care, 15(Suppl. 1), i66-i71. https://doi.org/10.1136/qshc.2005.015982

Banja, J. (2010). The normalization of deviance in healthcare delivery. Business Horizons, 53(2), 139-148. https://doi.org/10.1016/j.bushor.2009.10.006

Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses' workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13, Article 175. https://doi.org/10.1186/1472-6963-13-175

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768

Shojania, K. G. (2008). The frustrating case of incident-reporting systems. Quality and Safety in Health Care, 17(6), 400-402. https://doi.org/10.1136/qshc.2008.029496