workforce factors Appropriate rules/policies/procedure or lack thereof Failure to provide appropriate staffing or correct a problem Failure to provide necessary information Organizational Organizational-level failure to correct a known problem and/or provide resource support including culture/leadership staffing Workplace climate/institutional culture Leadership commitment to patient safety Table A-2. Action Strength Action Strength Action Category Example Architectural/physical plant Replace revolving doors at the main patient entrance into the building with powered Stronger changes sliding or swinging doors to reduce patient falls. Actions New devices with usability Perform heuristic tests of outpatient blood glucose meters and test strips and select (These tasks testing the most appropriate for the patient population being served. require less Engineering control (forcing Eliminate the use of universal adaptors and peripheral devices for medical reliance function) equipment and use tubing/fittings that can only be connected the correct way (e.g., on humans IV tubing and connectors that cannot physically be connected to sequential to remember to compression devices [SCDs]). perform the task Simplify process Remove unnecessary steps in a process. correctly) Standardize on equipment Standardize the make and of medication pumps used throughout the institution. or process Use bar coding for medication administration. Tangible involvement by Participate in unit patient safety evaluations and interact with staff; support the leadership RCA2 process (root cause analysis and action); purchase needed equipment; ensure staffing and workload are balanced. Intermediate Redundancy Use two registered nurses to independently calculate high-risk medication dosages. Actions Increase in staffing/decrease Make float staff available to assist when workloads peak during the day. in workload Software enhancements, Use computer alerts for drug–drug interactions. modifications
workforce factors Appropriate rules/policies/procedure or lack thereof Failure to provide appropriate staffing or correct a problem Failure to provide necessary information Organizational culture/leadership Organizational-level failure to correct a known problem and/or provide resource support including staffing Workplace climate/institutional culture Leadership commitment to patient safety Table A-2. Action Strength Action Strength Action Category Example Stronger Actions (These tasks require less reliance on humans to remember to perform the task correctly) Architectural/physical plant changes Replace revolving doors at the main patient entrance into the building with powered sliding or swinging doors to reduce patient falls. New devices with usability testing Perform heuristic tests of outpatient blood glucose meters and test strips and select the most appropriate for the patient population being served. Engineering control (forcing function) Eliminate the use of universal adaptors and peripheral devices for medical equipment and use tubing/fittings that can only be connected the correct way (e.g., IV tubing and connectors that cannot physically be connected to sequential compression devices [SCDs]). Simplify process Remove unnecessary steps in a process. Standardize on equipment or process Standardize the make and of medication pumps used throughout the institution. Use bar coding for medication administration. Tangible involvement by leadership Participate in unit patient safety evaluations and interact with staff; support the RCA2 process (root cause analysis and action); purchase needed equipment; ensure staffing and workload are balanced. Intermediate Actions Redundancy Use two registered nurses to independently calculate high-risk medication dosages. Increase in staffing/decrease in workload Make float staff available to assist when workloads peak during the day. Software enhancements, modifications Use computer alerts for drug–drug interactions.
RCACLEAN_Appendix_hmf_lh_LB_GC_7.13.17.docx