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Leadership Practices for Eliminating Patient Harm: Diagnosing

In the third part of our series on using leadership and adaptive practices to address prescription error, we learn what themes were generated from a listening tour and how action was taken on one of those themes. Our story continues as Marilyn selects a theme based on her and her colleagues’ analysis of the data.

The themes they ultimately propose from the verbatim responses are:

  1. Since the automation of the prescription system, almost everyone assumes that the electronically prescribed medication is accurate, timely and complete once it is in the system.
  1. There are periods during the day and night when employees are fatigued because of their workload. They accept that this will always be the case, and don’t raise it as an issue out of fear of being seen as “not a team player.”
  1. Some people have pointed out weaknesses in the prescription process to their supervisors, and, based on the lack of response, have given up on taking action to improve the process. They often hear that the annual target for reducing errors is being met, and therefore additional efforts are unneeded.
  1. Of those who have been trained on the use of the prescription system, some report that the training did not reflect how the system actually works. In response, they have created electronic and non-electronic “workarounds” to meet the needs of their particular areas.
  1. Patients are viewed as not able to fully understand their condition and its treatment, and therefore are not encouraged to understand their medication or its dosage. The ideal patient is one who passively accepts directions, procedures, and medications from the hospital staff.
  1. A theme emerged related to questioning the originating physician about a prescription. For nurses, pharmacists, and others, this would be a “career-limiting move,” and would be unacceptable if done by fellow physicians in or outside of the hospital.

Before Marilyn takes further action, she pauses to reflect. The themes from the listening tour represent obstacles to eliminating prescription errors. Yet, while everyone says flawless prescribing is a good idea, it’s difficult to know which of these obstacles requires urgent attention.

Marilyn considers how to communicate her findings to those from her listening tour, as well as how to share a theme with those accountable for its resolution. As part of her communication, she wants to hear back from her listening tour participants, and learn whether they are ready to take a theme and ripen it into an issue. She is also curious about whether they think a technical solution is available for any of the issues.

One of the listening tour participants and her first stop is her informational technology colleague, Harry. Harry is somewhat surprised at the workaround issue, and agrees that if even remotely accurate, it would be a higher priority than the other issues.

He suggests that if a team from the hospital attended the software vendor’s deployment intensive, the issues occurring due to the workarounds would be mitigated. While this may be an appropriate technical solution, Marilyn asks if Harry would be willing to perform his own listening tour to dig deeper into the issue, and expose the real work that needs to be done to address it.

After working to define a group of people responsible for addressing this issue, Harry agrees and provides a date by which he will complete his listening tour. The results of Harry’s listening tour will help them decide whether additional training is indeed a solution, and what other action might be required to resolve the issue.

In the fourth part of our series, we will learn how to work with people who avoid taking responsibility for engaging with an issue. If you have been following the series and testing your own capacity for adaptive work, then now would be the time to return to your original listening tour participants and share your themes. Keep in mind, during this stage people may or may not be ready to take action.


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