AHRQ Patient Safety Network

Workarounds and Resiliency on the Front Lines of Health Care AHRQ WebM&M icon

Tucker AL. AHRQ WebM&M [serial online]. August 2009.

Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock. Research suggests that hospital nurses experience an average of one of these "operational failures" per hour. Dealing with them takes valuable time away from patient care—an average of 33 minutes per nurse per 7.5-hour shift in my study. To put this in perspective, for every 15 nurses working on a unit, the equivalent of one nurse has been removed from patient care to work full-time obtaining required supplies, information, and equipment. In effect, work system problems increase a hypothetical ward nurse's workload from 5 patients to 5.3 patients, which research suggests contributes to staff burnout and may increase patient mortality by 2%. To make matters worse, other health care professionals, such as surgeons and anesthesiologists, also experience operational failures. The cumulative time spent tracking down necessary items quickly becomes staggering. More importantly, operational failures disrupt patient care, leading to uncompleted tasks and medical errors.

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