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Workarounds, or similar intentional violations of a rule or procedure, are very common in healthcare (see our Septemeber 4, 2007 Patient Safety Tip of the Week “Workarounds as a Safety Issue”). They are usually performed with the best of intentions and are usually an indication of a flawed or poorly designed underlying process or system. In fact, any time you see a workaround being performed, you need to look for the root causes that led to the need for a workaround.
In our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent” we described an incident we witnessed as we were doing our first electronic medical record implementation. A nurse was using a just-implemented barcoding system to perform medication administration. The bar code on one unit-dose medication would not scan properly because of a crinkle in the barcode. The nurse was to then manually input the barcode from the package onto the system computer. However, the print on the barcode was too small for her to read. She then prepared to cut and paste the medication number from the computer screen into the manual entry input box. That, of course, would have bypassed the whole patient safety concept of a barcoding system, which is to verify that the medication being given is the same as the one on the computer screen. Simply typing in those same numbers seen on the computer screen would have also bypassed the safety mechanism involved in barcoding. While we intercepted this instance to prevent a potential error, there are undoubtedly many similar workarounds being used with barcoding systems.
We wondered how often this type of barcoding system workaround occurred and whether there were other similar workarounds we needed to watch out for. Fortunately, Ross Koppel (Koppel 2008) and his colleagues had just published an article identifying the multiple types of workarounds in barcode systems and their underlying causes. They identified 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems.
It’s been over 4 years since we did our last column on workarounds. But in the last few weeks there have been two good studies on workarounds.
Researchers in the Netherlands performed a prospective observational study of nurses using barcode techniques to administer medication to inpatients (van der Veen 2020). Of almost 6000 medication administrations they observed, 62.7% involved one or more workarounds. They classified workarounds as:
(such as not scanning at all)
(such as no barcode wristband on the patient)
(such as scanning before actual administration of medication, scanning medication for more than one patient at a time, and ignoring computer or scanner alerts)
Potential risk factors associated with workarounds were the day of the week, the timing of the medication administration, the route of administration, the administration of medication from irregularly used classes and the patient–nurse ratio. Though they had no formal measure of nurse workload, the strongest association with workarounds was having the patient:nurse ratio equal to or greater than 6:1 compared to 5:1 or less (adjusted OR 5.61). Other factors, such as the percentage of barcoded medication and work experience, were not associated with workarounds.
We found interesting the association of the nonoral route of administration with workarounds. They provided several examples. Certain routes of administration, such as dermal or inhalation, are often left to the patient for self-administration, and nurses may forget to scan such medication. Another example is certain parenteral medications that need special handling to make it ready to administer (eg. an original vial with infusion powder may contain a barcode, but the infusion bag with the added drug may not be barcoded).
Workarounds were also associated with the time of the medication round and particular days. They were more likely on busy weekdays versus the relatively quiet Sunday (Wow, so much for our “weekend effect)!). Workarounds were also more likely on the rounds scheduled during the afternoon and evening compared to the morning. The authors attributed this to likely saving time during busier parts of the day.
The authors state “In particular, nurse workload and the patient:nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.” They note their findings emphasize the need to review the patient:nurse ratio, work schedules and medication-related workload per day of the week and per shift to ensure the safe use of the system. They stress the importance of a positive work environment and adequate balance between patients and available nursing care. Good timing, given our September 1, 2020 Patient Safety Tip of the Week “NY State and Nurse Staffing Issues”.
The second study was a review of the published literature on nurses’ use of workarounds related to the electronic health record (Fraczkowski 2020). A total of 33 articles met their inclusion criteria. The authors acknowledge that researchers often classify workarounds differently, but that they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes included technology, task, organizational, patient, environmental, and usability factors. They note that, compared to research done in acute care settings, there is a dearth of research on workarounds in the ambulatory setting. They conclude that, despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team.
Workarounds can be unique, simple or complex, and often extremely innovative. But remember: when you see a workaround, there is always an underlying root cause or causes that led someone to use that workaround. When we do Patient Safety Walk Rounds, one question we often ask nurses or other healthcare workers is “Are there any workarounds you sometimes do?”. It’s important you let them know ahead of time that this question is asked in a nonpunitive manner and is being asked in order to identify barriers or impediments to care and workflow. Importantly, you need to be prepared to address whatever root cause they reveal in their answers!
September 4, 2007 “Workarounds as a Safety Issue”
May 2008 “UK NPSA Alert on Heparin Flushes”
June 17, 2008 “Technology Workarounds Defeat Safety Intent”
September 15, 2009 “ETTO’s: Efficiency-Thoroughness Trade-Offs”
August 24, 2010 “The BP Oil Spill - Analogies in Healthcare”
March 6, 2012 “Lab Error”
July 2, 2013 “Issues in Alarm Management”
April 8, 2014 “FMEA to Avoid Breastmilk Mixups”
October 7, 2014 “Our Take on Patient Safety Walk Rounds”
April 5, 2016 “Workarounds Overriding Safety”
June 2016 “ISMP Article on Workarounds”
Koppel R, Tosha Wetterneck T, Telles JL, Karsh B-T. Workarounds To Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. Journal of the American Medical Informatics Association 2008; 15(4): 408-423
van der Veen, W, Taxis, K, Wouters, H, Vermeulen, H, Bates, DW, van den Bemt, PMLA; the BCMA Study Group. Factors associated with workarounds in barcode‐assisted medication administration in hospitals. J Clin Nurs. 2020; 29: 2239– 2250
Fraczkowski D, Matson J, Lopez KD, Nurse workarounds in the electronic health record: An integrative review, Journal of the American Medical Informatics Association 2020; 27(7): 1149-1165
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