E |  info@pandhmedical.co.uk

Pain assessment and management at triage is obviously important, but in one department I visited, there was no drug cupboard at triage. So the staff had worked around the system.  Rather than walking from triage, locating drug cupboard keys, obtaining one gram of paracetamol, giving the keys back to a member of staff in majors and going back to the patient in triage (several minutes later), a stash of paracetamol, NSAIDs and codeine were hidden in the triage desk draw.  Unlocked.  We all accepted this, not as ideal, but as the best solution until ‘someone’ sorted a drug cupboard.

Not everyone accepts analgesia at triage.  Some patients after waiting to be seen in minors are still in pain and require further analgesia.  In minors there was a locked drugs cupboard.  But as there are a number of staff who regularly require access to the drug cupboard, do you constantly interrupt your colleagues whist with other patients, trying to locate those keys, or do you leave the keys on a shelf above the computer, so it is easily accessible and thus prevent interruptions and delays?  Clearly neither of these solutions was ideal, but the latter, more risky strategy was often adopted.  

So a new small drugs cupboard was installed in the room behind triage, and an electronic drug cupboard into the main department.  Job done!  Or is it?
When you listen to Matt Parker, former head of Marginal Gains for the British cycling team, the reason that the team has been so successful is that they constantly look for small incremental changes that will shave a 100th of a second off here and a 10th of a second off there.  When translated to caring for patients at triage or in minors, shaving 2 minutes off the time to see 30 minors patients seen in a shift, releases an hour of time, enabling another 4 patients to be seen. 
It is more time consuming to get up and get the analgesia from the next room at triage, and to walk to the drugs cupboard, key in patient details and drug requirement than having a stash of pills in the triage draw, or in your pocket.  We did not address the culture.

Amalberti’s model of system migration and transgression in practice suddenly made sense.  We had been operating in the ‘illegal normal’ zone in my department regarding the medicines code.   Many people routinely drive 80 miles per hour on the motorway despite being aware that this is above the legal limit.  And which of us would question this or suggest to a colleague that this isn’t advisable?  This is ‘the normalisation of deviance’.  This is pills in the pocket in my department.  However the department should be more akin to a 50 zone, and then 80mph is clearly not acceptable.
The initial safe space of action, as defined at the design stage, is usually much narrower than the range of operation in actual practice. External pressures on performance, from the organization or from individuals, make migration of the system almost unavoidable. Normally, migration is limited to borderline tolerated conditions of use (BTCUs) in which staff tacitly accept routine minor violations. However, some individuals commit more extreme violations, either because of personal characteristics or because of exceptional circumstances, whether real or imagined. The behaviour of these people may encourage further extreme violations in other staff.   Qual Saf Health Care. Dec 2006; 15(Suppl 1): i66–i71.

Culture is created by people and, in turn, their behaviour is moulded by the culture they work in. Solutions that work around a problem, such as keeping prescription medications in an unlocked drawer because it is too time consuming to adopt the ‘correct’ behaviours, are likely to be commonplace in all our workplaces. Once these ‘work-arounds’ are discovered it is important we pay attention to why this is happening as well as prevent unsafe practices from becoming embedded. In my example the staff did not deliberately break the rules due to due to any malicious intent, it was so they could see patients in a more timely manner. Wanting to do what is best for the patients is clearly a good thing and something we should encourage. Consequently, as leaders we need to ask what can we do to ensure that ‘work-arounds’ are not necessary.

Pills in pockets and keys on shelves are not something usually measured or reported.  What else is going on unrecognised or unchallenged that is unsafe? Can safety be measured in a metric like time-based quality indicators?  When safety fails, the results of non-safety can be measured (e.g. clinical incidents), but the root cause is a narrative personal to that department and hospital’s systems and culture.
By Dr Sally-Anne Wilson