FIXES THAT FAIL
In a fixes that fail scenario, a problem symptom presents (e.g., a nurse needs to get new bed linens for a patient, but her unit has run out of clean linens). The obvious course of action is to implement a solution that alleviates a symptom (e.g.,going to another unit to get bed linens). The solution, however, fails to address the root cause of the problem (e.g., increased laundry services for the hospital), and eventually the problem symptom returns or worsens.
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Problem of Practice No. 2 draws on the article Why Hospitals Don't Learn from Failures by Anita Tucker and Amy Edmondson. They examine how nurses on the hospital frontlines respond to the daily problems they encounter in trying to care for patients. They found that nurses overwhelmingly used a quick fix to solve obstacles that prevented them from delivering continuous patient care. While this strategy allowed them to continue caring for their patients, it did little to support organizational learning.
To more deeply understand the quick fix and its relationship to a hospital's ability to learn, we invite you to explore the dynamic systems thinking model below.