There two key factors that influence the caregiver's decision about adopting new practices. First, the practice changes you are asking them to make must have been proven to be the right thing to do. Unless a valid research study has substantiated the benefits of the new way of doing things, it's hard to create much enthusiasm for change. Second, the caregivers being asked to change their practices must personally feel it's the right thing to do. People should acknowledge that the practice change is a good thing for them and for their patients. If one or both of these criteria are not met, you are likely to find significant resistance to change.

If both of the criteria described above have been met and caregivers still slip back into their old habits, then what you are probably dealing with are human errors. When caregivers omit necessary steps in a patient care process, there are several possible reasons for their action:

* A necessary step might be unwittingly overlooked (a mistake)

* The step is deliberately left out of the process (a violation)

* The caregiver intended to care out the step, but the right thing to do was not recalled at the appropriate time (lapse)

* The clinical situation is atypical or the process steps do not proceed as usual and the necessary action is unwittingly omitted (a slip)

James Reason, internationally known expert in the cause and correction of human errors, suggests that the simplest countermeasure for preventing errors is an appropriate reminder.(2) Listed below are some of his suggestions for what a good reminder system should be. Many of these characteristics could be applied to reminders used in patient care processes.

* Reminders should be conspicuous; the person's attention must be attracted at the critical time.

* Reminders should be located as close as possible in both the time and distance to the to-be-remembered task.

* Reminders should provide sufficient information about when and where the required step should be carried out.

* Reminders should allow the person involved to check off the discrete actions or items that are included in the correct performance of the task.

* Where possible, the reminder system should block further progress until the necessary step has been completed.

As your clinicians design outcomes management reminder tools (clinical pathways, protocols, care planning aids, computer-based decision support, etc.) tell them to keep Reason's suggestions in mind. The presence of reminders does not guarantee that clinicians will automatically change their behavior, however reminders are likely to bring about a substantial reduction in noncompliance that is due to simple human error.

(1) Mahon SM et al. "Safe Handling Practices of Cytotoxic Drugs: The Results of a Chapter Survey," Oncol Nurs Forum 1994; 21(7): 1157-65.

(2) Reason, James. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing, Ltd. 1997.

Copyright 2001 by Brown-Spath & Associates