First- and Second-Order Problem Solving: When Rework and Workarounds Become an Opportunity for Improving Safety

The patient’s nurse further explained that the medications were overdue according to the EHR, and she believed that because she “knew the patient,” she could scan the bracelet attached to the stretcher and administer the medications as soon as possible, and then when time permitted, she would obtain a new bracelet.1 Nurses encounter numerous day-to-day systems-based failures or breakdowns in processes, resulting from, but not limited to, challenges with the use of new technology, the environment, staffing, availability of patient or drug information, or drug shortages and distribution.2,3 In fact, according to Tucker,4,5 nurses encounter roughly one system failure an hour (6.5 failures per 8-hour shift), which equates to “removing” one out of every 15 nurses from patient care just to deal with the failures each day. Health care workers are often proud when they overcome obstacles in patient care, even though it may mean taking shortcuts, breaching policies and procedures, or working around systems as designed.6 Organizational cultures regularly reward nurses who use creativity when systems don’t work as designed, referring to these nurses as flexible, highly resourceful, and resilient.2-4,6 Tucker4,5 suggests that nurses use first-order problem solving to implement short-term “fixes” 93% of the time when they encounter a system failure. According to research, “fixing and forgetting” was the predominant choice of health care practitioners when faced with problems that they could resolve themselves, even if it involved a workaround or recurring problems that threatened patient safety.9 The lack of second-order problem solving is impeding our safety journey.