Why Do Well-Meaning Personnel Disable Safety Devices?

R ecently, the Patient Safety List-serve addressed the fact that OR personnel were removing the sliding safety shield from syringes used in the OR because they felt that the cover interfered with the basic use of the device. On another occasion, a hospital reported that nursing personnel were removing a flip-up postuse cover from their syringes before they used them (by cutting it off) because they found that the cover piece interfered with their clinical task. These instances reflect the general problem of safety considerations resulting in the deployment of devices with safety features that are at least alleged to reduce risk, but which the frontline personnel not only use improperly but they actually actively defeat the feature. Although there can be a number of reasons for this, the safety syringe situation focuses on the deliberate nonuse or defeat of a safety feature with the wellmeaning intent of improving clinical performance. This situation presents a number of difficulties. One is that if the selection and deployment of the safety system was rational, then a desired and possible improvement in safety that could be achieved is not. Second, safety systems often have an upfront price premium so that if the safety features are ignored or disabled money is being wasted. Third, if an adverse event does occur, the fact that personnel were not following the institution’s own established procedures aimed at preventing exactly that type of incident could become a challenging postincident risk management issue. An important question then is why do personnel deliberately defeat a safety feature? In this case, it is clearly not because they do not know the correct procedure. In this regard, additional procedural training is unlikely to achieve a measurable result. The more fundamental issue is the actual performance of the device relative to the staff’s perception, and the staff’s ability to communicate their issues to the appropriate management personnel. One possibility is that the staff is right—the safety feature does in fact interfere with normal or preferred practice. If this is the case, then either the design is actually unacceptable or the enhanced safety is worth the degradation in practice. Note that in the case of some anti-needlestick devices this would be a transfer of risk from healthcare personnel (who are the most common victims of inadvertent needlesticks) to patients. Furthermore, the administrative coercion necessary here is an attempt to mandate and to enforce what the users believe to be degraded patient care. The other possibility is that the staff is wrong—appropriate and consistent patient care can be achieved under realistic conditions while using the safety accessory as intended. If this is the case, then there may be inadequate training and, more importantly, practice in the use of the new device. The ‘‘learning curve’’ must be taken into account here with respect to how much experience with the device is necessary before real proficiency is achieved, and how to get past the lag time until Journal of Clinical Engineering