What’s that barrier protecting?
Patient Safety Quality Monthly
August 25, 2010
In patient safety and quality, we regularly talk about barriers. Sometimes they are the bad barriers such as a barrier to acceptance of a safer way to work, and sometimes they are positive barriers that are there to protect us, such as a double-check or an equipment guard or a locked door. We often think the more positive barriers the better. But is that really so? We need to carefully think about what harm the barriers are protecting us from and ensure that there are no unintended consequences.
Let's consider a couple of simple examples.
One of the risk areas in the nursery is the potential for abduction of a newborn, so it is natural that we think about adding barriers to protect them, such as lockdowns based on a protection band on the baby that causes the doors to automatically lock. Seems like a good barrier. Maybe we have even recommended it for our facilities.
Ideally that barrier will keep the abductor and the newborn on the nursery side of the door and prevent them from running off so the nursing staff or security can deal with the situation. But are there potential unexpected consequences of this? Absolutely. The classic example, which isn't that unusual, is for the abductor to slip out the door just as the lockdown is triggered, thereby locking in the responders instead of the culprit. Then there is much running back and forth to the override switch to open the doors so the situation can be resolved. The barrier could end up working backwards, keeping the good guys locked in giving the bad guys a head start. In this case, the unexpected consequences of our barrier might outweigh the benefits.
Another example involves the scrubs that so many nurses, surgeons, physicians, and technicians wear. These are designed as barriers to keep contamination away from the wearer and also to keep from spreading contamination around the hospital. But has your organization clearly stated what they are barriers for? Are they a barrier to protect the care provider or the facility or patient or maybe all three. Can we really be sure that this barrier is effective if we haven't clearly defined why we have it?
Shoe covers can protect the surgeon's shoes from spills in the OR, but when they are worn down the street to the fast food joint, they pick up all kinds of dirt that is then tracked back into the hospital. Gown and gloves worn for a bedside procedure help protect the physician, but also help preserve the cleanliness of the procedural area. Typically, protective clothing is worn to protect the wearer from harm AND to prevent the spread of contamination. Are your barriers causing unexpected consequences and maybe spreading contamination rather than doing their job?
This certainly doesn't mean that we shouldn't have barriers—they are a necessity in our world. However, we need to be smarter than the barrier and make sure it is keeping the bad stuff on the right side!
Ken Rohde, Senior Consultant, August 2010
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