762546 HFSXXX10.
1177/0018720818762546Human FactorsWorkarounds with HIT
Workarounds to Intended Use of Health
Information Technology: A Narrative Review of
the Human Factors Engineering Literature
Emily S. Patterson, Ohio State University, Columbus
Objective: To integrate and synthesize insights
from recent studies of workarounds to the intended
use of health information technology (HIT) by health
care professionals.
Background: Systems are safest when the documen-
tation of how work is done in policies and procedures
closely matches what people actually do when they are
working. Proactively identifying and managing workarounds
to the intended use of technology, including deviations
from expected workflows, can improve system safety.
Method: A narrative review of studies of work-
arounds with HIT was conducted to identify themes in
the literature.
Results: Three themes were identified: (1) Users
circumvented new additional steps in the workflow
when using HIT, (2) interdisciplinary team members
communicated via HIT in text fields that were intended
for other purposes, and (3) locally developed paper-
based and manual whiteboard systems were used
instead of HIT to support situation awareness of indi-
viduals and groups; an example of a locally developed
system was handwritten notes about a patient on a
piece of paper folded up and carried in a nurse’s pocket.
Conclusion: Workarounds were employed to avoid
changes to workflow, enable interdisciplinary communi-
cation, coordinate activities, and have real-time portable
access to summarized and synthesized information.
Application: Implications for practice include pro-
viding summary overview displays, explicitly supporting
role-based communication and coordination through
HIT, and reducing the risk to reputation due to elec-
tronic monitoring of individual performance.
Keywords: workarounds, health information technol-
ogy (HIT), patient safety, nursing and nursing systems
Address correspondence to Emily S. Patterson, School of
Health and Rehabilitation Sciences, College of Medicine,
Ohio State University, 210 Baker Systems, 1971 Neil Ave.,
Columbus, OH 43210, USA; e-mail: Patterson.150@osu.edu.
HUMAN FACTORS
Vol. XX, No. X, Month XXXX, pp. 1­–12
DOI: 10.1177/0018720818762546
Copyright © 2018, Human Factors and Ergonomics Society.
Introduction
In this paper, I identify themes regarding
how health care professionals use systems in
unintended ways, called workarounds, based
on a narrative literature review. Some work-
arounds are dangerous for patients and should
be reduced, and some workarounds are useful
and thus provide insights for how to improve
systems. By understanding the types and rea-
sons for workarounds, systems can be made
safer through changes to the system design or
implementation.
A workaround is defined (similar to Alter,
2014) as: a deviation from an intended work
process, which is used to overcome an obstacle,
by a practitioner responsible for meeting a work
demand; the deviation is likely an active adapta-
tion to the process that is documented in policies
and procedures. This definition is based on a dis-
tinction between the view of work that is docu-
mented in formal policies and procedures, called
work-as-imagined (WAI), and what experts
actually do when they are working, which is
referred to as work-as-done (WAD; Hollnagel,
Braithwaite, & Wears, 2013). One reason for the
difference between what is done and what is
documented in procedures is that experts must
resolve conflicting goals to achieve their work
objectives (Hollnagel, 2014). Failing to resolve
goal conflicts in a timely fashion can have high
consequences for failure in complex settings,
such as failing to notice a need to deliver medi-
cations to restart a heart that had unexpectedly
stopped during surgery because the anesthesiol-
ogist was navigating between electronic dis-
plays (Cook & Woods, 1996). As new technol-
ogy increases the complexity of work settings,
resolving goal conflicts is likely to involve
deciding when to sacrifice one goal for another.
For example, in a time-pressured situation such
as receiving the full dose for a chemotherapy
medication delivered intravenously (by IV) in
2 Month XXXX - Human Factors
an outpatient setting before the clinic closes, it is
recommended for a pharmacist to use an admin-
istrative login to order a medication even though
typically only physicians are allowed to do so.
With this login, the pharmacist can correct a
mistake made by a physician, such as failing to
include a space between the name and dose of a
medication in a medication order (e.g., 20mg
instead of 20 mg) (Patterson, Rogers, & Render,
2004). When using this workaround, the goal of
limiting the task of medication ordering to the
personnel who have been trained to do the task
is sacrificed in order to have the medication
ordered early enough to avoid having the patient
stay overnight in the hospital.
Workarounds have been identified in settings
other than health care. For example, Vicente
(1999) identified workarounds employed by
graphic designers with the use of a particular
software package. One example of a work-
around was printing two alternative design pro-
posals to view them in parallel at the same time
rather than viewing one design proposal at a
time electronically in the software. In another
study in nuclear power control rooms, Mumaw,
Roth, Vicente, and Burns (2000) observed that
operators expanded the y-axis for a parameter
value on a trend plot that included historical data
on the computer screen to monitor minor
changes in that parameter. In a related study,
Vicente, Roth, and Mumaw (2001) observed
that operators customized a set of trend plots so
that they could monitor several variables con-
tinuously during a refueling activity.
Prior research on workarounds has identified
a variety of approaches to take in response to the
discovery of the existence of workarounds.
These approaches are:
•• Reduce dangerous workarounds by reducing the
need to circumvent the processes and procedures
(Hollnagel, 2014; Reason, 1990): “Workarounds
can be dangerous, and they should be monitored
and, where possible, standardized” (Vogelsmeier,
Halbesleben, & Scott-Cawiezell, 2008, p. 114). An
example of a dangerous workaround done by nurses
using bar code medication administration (BCMA)
software was to prepare medications for multiple
patients at once before administering them to indi-
vidual patients. Nurses scanned the barcode for the
medications, opened the packages, placed the unla-
beled medications into a paper cup in the patient’s
medication drawer, and then stated that they would
administer the medications in the cup to an unavail-
able patient when he or she returned to the hospital
room. In this way, the automatically documented
administration time occurred within the intended
time window for the medication pass. Scanning
within the time window also enabled the nurse to
avoid setting down the barcode scanner to type a
reason for each medication for why it was adminis-
tered late. This workaround is dangerous in that the
unlabeled medications in an unlabeled cup could be
documented as administered but never received by
the patient (Patterson, Rogers, Chapman, & Render,
2006).
•• Support professionals in deciding when to use
workarounds. For example, team-based train-
ing in simulated environments has been shown
to help teams be prepared to overcome obstacles
to achieve work objectives (Gorman, Cooke, &
Amazeen, 2010).
•• Reward professionals who appropriately use
workarounds or develop useful workarounds,
which are then incorporated into formal proce-
dures and systems (Clancy, 2010).
•• Incorporate useful workarounds: “Hacks and
workarounds are the soul of innovation” (Norman,
2008, p. 47).
Regarding the last approach of incorporating
useful workarounds into the formal system, they
are typically active adaptations employed by
experts. Active adaptations are often needed in
complex work settings to address goal conflicts
and workload bottlenecks (Woods, 2006). In
many cases, new technology increases the cou-
pling between existing systems, thereby leading
to more complexity and less flexibility. Simi-
larly, new technology is typically designed to
increase efficiency by automating activities, and
there are situations where the automation does
not work correctly and thus requires human
oversight (Sarter & Woods, 1995). Therefore,
it is expected that some workarounds will be
conducted to address goal conflicts, reduce
workload bottlenecks, reduce coupling between
related systems, or address exceptional situa-
tions where the automation does not meet work
demands appropriately (i.e., “is brittle”).
Workarounds with HIT
In health care, there has recently been a trans-
formation of a number of paper-based systems to
electronic-based health information technology
(HIT). HIT is information technology that sup-
ports health information management and the
secure exchange of information. HIT is used in all
settings of care, including hospitals, and is used
by a wide variety of health professionals. An
example of HIT is electronic health records
(EHRs), which enable the electronic management
of health information for patients, including elec-
tronically ordering medications by physicians
and administering medications with the support
of barcoded wristbands and medications by
nurses. A common experience during the imple-
mentation of new HIT is for users to actively
work around using the HIT as intended and in
particular to revert to prior paper-based systems.
By proactively identifying how and why users
work around HIT, the system software can be
redesigned, and the implementation aspects of the
system can be improved. For example, it can be
dangerous when a physician verbally tells a clerk
to order a medication for a patient (a so-called
verbal order) because then a pop-up dialog warn-
ing box that a patient is allergic to a medication is
not incorporated into the physician’s decision-
making process for the order.
From a theoretical perspective, HIT is
unlikely at first to completely match the useful-
ness of paper and whiteboards because the use
has evolved over time to support active adapta-
tions in a flexible manner (Perry & Wears,
2012). Four elements of how paper-based sys-
tems and whiteboard systems support active
adaptations have been identified in prior research
in health care as well as other settings. These
elements are (1) portability in that paper can be
physically carried around, (2) collocated access
in that whiteboards or multiple printouts can be
annotated and updated by more than one person
simultaneously when the people are in the same
physical location, (3) a shared overview in that a
group can collectively view and point to items
on a whiteboard or multiple printed pages dis-
played on a wall, and (4) mutual awareness in
that the characteristics of papers or paper files
can be used to communicate status, such as by
“cocking” a paper card to indicate that a plane
being managed by an air traffic controller has an
3
issue with the flight plan (Bardram & Houben,
2017).
Method
Studies of workarounds with HIT were
assessed with a narrative review (K. Jones,
2004). Most articles were identified based on
forward and backward citation searching from
the key articles in Table 1. No date range
restrictions were applied. Also, relevant articles
with empirical data or literature reviews were
identified by scanning titles and abstracts from
searching in Google Scholar and Medline with
the terms work-around, workaround, and work
around. Inclusion criteria were that the abstract
text included relevant content, as judged by the
sole researcher. An iterative analysis using the
constant comparison method (Glaser & Strauss,
1967) with no a priori hypotheses was used to
identify themes by the author.
In total, 24 key articles and 80 on-topic arti-
cles were used in the narrative review. As dis-
played in Table 1, the contributions from the key
articles were identified and grouped into three
emerging themes and a set that provided theo-
retical foundations such as the definition of a
workaround for all themes. The three themes
that emerged were: (1) Nurses circumvented
new additional steps in the workflow when using
BCMA software, (2) interdisciplinary team
members communicated via HIT in text fields
that were intended for other purposes, and (3)
locally developed paper-based and manual
whiteboard systems were used instead of HIT to
better meet the needs of individuals and groups.
Results
Theme 1: Users Circumvented New
Additional Steps in the Workflow When
Using HIT
For the first theme, research investigators
documented when nurses employed work-
arounds for the intended use of a relatively
new HIT, bar code medication administration.
BCMA is software used by nurses to verify
that a medication, which is being prepared by
the nurse, was ordered for the particular patient
for that time by scanning a patient’s barcoded
wristband as well as a barcode on the individual
4 Month XXXX - Human Factors

Table 1: Theme, Reference, and Main Contribution of Key Articles

Theme Authors (Year) Main Contribution

1 Agrawal and Glasser (2009)
1 Cresswell, Mozaffar, Lee, Williams, Workarounds with electronic prescribing systems
and Sheikh (2017)
1 Greenfield et al. (2017)
1 Hardmeier, Tsourounis, Moore,
Abbott, and Guglielmo (2014)
1 Horsky, Drucker, and Ramelson
(2017)
1 Koppel, Wetterneck, Telles, and
Karsh (2008)
1 Niazkhani, Pirnejad, Berg, and
Aarts (2009)
1 Patterson, Cook, and
Render (2002)
1 Rack, Dudjak, and Wolf (2012)
1 Taliercio et al. (2014)
1 van der Veen et al. (2017)
1 Vogelsmeier, Halbesleben, and
Scott-Cawiezell (2008)
2 Goh, Gao, and Agarwal (2011)
2 Holden, Rivera-Rodriguez, Faye,
Scanlon, and Karsh (2013)
3 Flanagan, Saleem, Millitello, Russ, Empirical findings about workarounds with EHR use
and Doebbeling (2013)
3 Gurses, Xiao, and Hu (2009)
3 Wears, Perry, Wilson, Galliers, and Empirical findings about a locally developed whiteboard
Fone (2007)
3 Xiao, Lasome, Moss, Mackenzie,
and Faraj (2001)
Case study of avoiding workarounds with bar code
medication administration by nursing personnel
Barriers to intended use of electronic medication
management systems by nursing personnel
Compliance rate with safety processes; empirical findings
on workarounds for the intended use of bar code
medication administration by nursing personnel
Reported routine workarounds for the intended use of
electronic medication reconciliation tool by physicians
Empirical findings on workarounds for the intended use of
bar code medication administration by nursing personnel
Literature review includes identifying that workarounds
with EHR reduce interruptions and other disruptions to
workflow
Empirical findings on unintended consequences with use of
bar code medication administration by nursing personnel
Clinical scenarios identified where four types of
workarounds are necessary during use of bar code
medication administration by nursing personnel
Predicted barriers and facilitators to acceptance of a
proposed bar code medication administration system
software for nursing personnel
Workarounds with bar code medication administration
by nursing personnel were associated with medication
administration errors; the frequency of types of
workarounds are reported
Empirical findings on workarounds with bar code
medication administration by nursing personnel
Narrative networks model how HIT and routines co-evolve,
including the use of unstructured text fields to
communicate with other disciplines
Empirical findings about workarounds for the intended
use of bar code medication administration by nursing
personnel
Empirical findings about functions of an extensive locally
developed system
system
Empirical findings about a locally developed whiteboard
system
(continued)
Workarounds with HIT 5

Table 1: (continued)

Theme Authors (Year) Main Contribution

4 Alter (2014) Review of definitions of the term workaround

4 Ash, Berg, and Coiera (2004) Empirical findings about unintended consequences of HIT
use, including workarounds
4 Espin, Lingard, Baker, and Regehr Organizational and cognitive psychology factors
(2006) contributing to persistence of unsafe work practices
4 Friedman et al. (2013) Typology of workarounds with EHR use
4 Kobayashi, Fussell, Xiao, and Empirical findings about features of workarounds in a
Seagull (2005) hospital environment
4 Novak (2012) Hidden work revealed by bar code medication
administration use by nursing personnel

Note. EHR = electronic health record; HIT = health information technology; 1 = circumventing new additional steps
in workflow during use of health information technology; 2 = interdisciplinary team members communicate via
unstructured text fields intended for other uses; 3 = locally developed manual whiteboard system fills gaps in HIT
functionality for coordination; 4 = theoretical foundations and definitions.

medication packet. Six studies are described
regarding this theme.
In the first study (Vogelsmeier et al., 2008),
two types of workarounds were identified,
which were used by nursing home staff with
BCMA to circumvent new tasks: (1) overriding
safety check alert pop-ups without reading them,
including warnings that the medication was not
ordered for the patient whose wristband had
been scanned, and (2) avoiding talking with
physicians or pharmacists to confirm that unusu-
ally high doses of ordered medications were cor-
rect. The administration of a dose that was
flagged by the software as potentially too high
was conducted as a workaround by scanning and
administering multiple lower doses of the same
medication, which added to the original ordered
dosing amount.
In the second study, workarounds with
BCMA used by nursing staff were categorized
(Koppel, Wetterneck, Telles, & Karsh, 2008)
into: (1) steps performed out of sequence, (2)
unauthorized process steps, (3) task-related
causes such as giving emergency stock medica-
tions that could not have orders entered by phy-
sicians and verified by pharmacists prior to
timely administration, (4) organizational causes
such as pharmacies sending only partial doses,
(5) patient-related causes such as patients refus-
ing medications, and (6) environmental causes
such as hospital areas lacking wireless connec-
tivity. An example of the unauthorized process
step workaround was placing a “surrogate”
patient’s wristband somewhere other than on the
patient to avoid having to physically travel to a
patient to scan the wristband. Alternative loca-
tions for the patient’s wristband included on
computer carts, scanners, doorjambs, and rings
worn on the nurse’s belt.
In a third study (Patterson, Cook, & Render,
2002), empirical findings included: (1) increased
confusion when the software took strong actions
that were not easily transparent for the user (Sar-
ter, Woods, & Billings, 1997), for example, the
system automatically removing medications not
administered during the scheduled time window,
which was typically four hours, without inform-
ing the nurse; (2) skipping the step of scanning a
patient’s wristband; and (3) “gaming” the sys-
tem by appearing to take intended actions as
viewed by a distant supervisor while not actually
doing so in the work setting (Woods & Shattuck,
2000), for example, batch scanning medications
intended to be administered at a later time dur-
ing the intended time window to avoid being
documented in the system as administering a
medication late.
In a fourth study, Hardmeier and colleagues
(2014) identified BCMA workarounds on two
pediatric units and one neonatal unit in a
6 Month XXXX - Human Factors
California hospital. Three workarounds were
identified, all of which increased efficiency by
dropping or changing the sequencing of activities
intended to enhance patient safety: (1) not visually
confirming the patient’s identification, (2) not
comparing the medication to the electronic medi-
cation administration record twice before admin-
istration, and (3) documenting a medication as
administered before actual administration.
In a fifth study (Greenfield et al., 2017), inter-
views with 19 acute care nurses who used elec-
tronic medication management systems at two
Australian hospitals revealed barriers to intended
use of the system. Barriers included availability of
the hardware and software, properties of the soft-
ware, competing demands, time pressure, and the
professional identity of the nursing role. An exam-
ple of a workaround was administering a medica-
tion to a patient and then later documenting it as
given in the electronic medication administration
record and thus avoiding taking the computer on
wheels (COW) into the room and verifying the
patient’s identity using the system. This work-
around was more efficient in that there were fewer
steps in the process and nurses did not have to wait
until a COW became available. In addition,
avoiding bringing cords into the patient’s room
reduced the risk of a patient fall and eliminated
the need to disinfect the equipment for patients
isolated due to infection. At one of the hospitals,
nurses risked being prematurely logged out of
the system and thus losing entered information if
they waited to document the medication as
administered until later and so routinely docu-
mented prior to administration.
In the sixth and final study, van der Veen and
colleagues (2017) observed nurses using BCMA
in Dutch hospitals. The study findings revealed
that the rate of medication administration errors
and frequency of workarounds were correlated.
The most common workaround was to skip
scanning barcodes, particularly when patients
did not have a barcoded wristband to scan. In
addition, nurses scanned medications other than
the ones intended to be administered and ignored
alerts. The most frequent medication administra-
tion errors were omissions, many of which
would not necessarily have been detected by
scanning wristbands and barcoded medications
but also included administration of nonordered
drugs and wrong dose errors, which would have
been caught without workarounds.
Theme 2: Interdisciplinary Team
Members Communicated via HIT in
Text Fields That Were Intended for
Other Purposes
Across several of the studies, another type of
workaround emerged, where professionals found
ways to communicate with other disciplines via
the HIT that were not explicitly designed into
the system. Typically, an unstructured text field
that was intended for storage and recall in a
database was “co-opted” in that the content was
used for communication rather than storage and
for content that was different than intended. One
example of a co-opted field was when a primary
care physician wrote in an electronic health record
post-it note feature that a patient went on a fishing
trip at the last outpatient visit; in this way, staff
could know to ask the patient how the trip went
at the next visit (Lowry et al., 2014). As another
example, Goh, Gao, and Agrawal (2011) found
that physicians wrote detailed instructions for
pharmacists on how they wanted so-called “taper
doses” to be reduced over a multiday period in
a free-text field in computerized physician order
entry (CPOE) software. Unfortunately, this com-
ments section had to be opened to view the infor-
mation, and it was not known that the field was
populated until it was opened. Similarly, a BCMA
study (Holden, Rivera-Rodriguez, Faye, Scanlon,
& Karsh, 2013) found that nurses used a text note
feature in BCMA to document actions and rea-
sons for medication administration discrepancies
that did not match pre-identified structured field
options. This workaround was used both when
there was no other way to communicate as well
as when other ways were possible but were harder
to access when the EHR was in use or took more
time to use.
Theme 3: Locally Developed Paper-
Based and Manual Whiteboard Systems
Were Used Instead of HIT to Better
Meet the Needs of Individuals and
Groups
With this theme, what emerged as related
across paper-based and manual whiteboard
Workarounds with HIT
systems was that their use was locally devel-
oped to fill gaps in functionality with the EHR
and related HIT. In particular, the locally devel-
oped systems supported both individual and
shared situation awareness in a variety of ways.
In one study (Patterson, Rogers, Tomolo,
Wears, & Tsevat, 2010), an electronic white-
board in the emergency department was found to
be used less extensively and have less up-to-date
information than the manual whiteboard with
redundant information. The manual whiteboard
was actively discouraged for use by the hospital
to enable automated calculation of patient
throughput times using the EHR. Functionality
that was better supported by the manual white-
board than the EHR and related HIT included
tracking real-time changes to EHR information,
facilitating shift change handovers, informing
physicians and nurses about newly assigned
patients, and informing physicians of the status
of ordered items. In a second study, Xiao and
colleagues (2007) identified that a shared inter-
disciplinary manual whiteboard in the operating
room provided an ability to jointly negotiate
resolutions to how to allocate work real time in a
highly uncertain and dynamic work environ-
ment. A third study (Wears, Perry, Wilson, Galli-
ers, & Fone, 2007) found that manual status
boards in the emergency department enabled
local control of how tasks were allocated among
interdisciplinary team members. Also, the orga-
nizing principle of the board on the left was the
physical location of patients (bed number), with
information in columns farther to the right being
progressively more uncertain. Finally, a fourth
study found that shared public displays in trauma
centers enabled economically broadcasting
time-sensitive information to interdisciplinary
team members (Xiao, 2005).
For support of an individual’s cognitive work,
some studies identified that sophisticated paper-
based systems were preferentially used over
EHR and related HIT. For example, Blaz, Doig,
Cloyes, and Staggers (2016) found that nurses in
hospitals relied heavily on personally created
handwritten paper sheets with patient summa-
ries to support shift change handovers, provid-
ing care to patients, and tracking planned activi-
ties throughout the shift. These paper sheets
were not documented in policies and procedures
7
or integrated with the EHR. A second study
(Gurses, Xiao, & Hu, 2009) found that nurse
coordinators in hospitals utilized personally cre-
ated paper sheets with handwritten notes. These
paper sheets were created twice a day to select,
reduce, organize, and annotate information that
could be accessed in a mobile, rapid fashion and
support note-taking under time pressure. In one
study at three institutions that discouraged the
use of paper, all uses of paper were catalogued
(Flanagan, Saleem, Militello, Russ, & Doebbel-
ing, 2013). The authors found that paper was
used for efficiency; as a memory aid; to support
situation awareness; to have an easier process; to
have a simpler or effective workflow; due to
higher trust in the data accuracy; to view the data
in a different layout or over a longer time period;
to customize information for a particular patient,
provider, or department; and to enhance mobil-
ity and access.
Discussion
The narrative review confirms that danger-
ous workarounds exist that should be reduced
to improve safety. In addition, there are posi-
tive workarounds that provide insights for how
to improve the usefulness of HIT and related
systems. This review extends our understanding
of the types and reasons for workarounds and
thus has implications for theory, managing risk,
practice, and future research.
Implications for Theory
In prior research, clinical personnel were
found to continuously prioritize multiple ongo-
ing threads of activity at a time, a cognitive
skill referred to as stacking (Patterson, Ebright,
& Saleem, 2011). Interruptions make this task
challenging and impact all levels of situation
awareness (Sitterding, Ebright, Broome, Pat-
terson, & Wuchner, 2014). Situation awareness
(SA) is the process of interpreting environmen-
tal and system information, with the first level
of SA defined as perceiving relevant informa-
tion, the second level integrating information
with task goals, and the highest level predicting
future events and system states (Endsley, 1995).
Interrupted tasks are associated with the failure
for physicians to return to complete 18.5%
8 Month XXXX - Human Factors
of tasks, leading to unfinished or missed care
activities (Westbrook et al., 2010). In a literature
review, it was found that unfinished or missed
care activities by nursing personnel was a pre-
dictor of decreased nurse-reported care quality,
patient satisfaction, patient safety with respect
to increased adverse events, nurse satisfaction
as indicated by increased turnover and intent
to leave, as well as self-reported job and occu-
pational satisfaction (T. L. Jones, Hamilton, &
Murry, 2015).
In prior research, one cognitive strategy
employed by experienced registered nurses was
the use of paper-based memory aids (Ebright,
Patterson, Chalko, & Render, 2003). This review
adds the insight that this strategy continues to be
employed after the implementation of EHRs and
thus is a workaround to the intended use of the
HIT. In addition, the review identifies that the
purpose of the workaround is to have real-time,
portable access to personally generated, summa-
rized, and synthesized information. Therefore, a
reasonable conclusion is that the workaround is
a memory aid that supports SA. In a similar
manner, the manual whiteboards, which are
workarounds to the intended use of the elec-
tronic whiteboard software, serve as memory
aids. For whiteboards, this review adds the
insight that the SA support is at the level of a
team of interdisciplinary team members and a
key aspect of the support is highlighting the
uncertainty of information in that more certain
information was displayed on the left of the
board.
Implications for Managing Risk
This research sheds insight into how to man-
age risk due to workarounds.
Enhance support for interdisciplinary commu-
nication with unstructured text shared asynchro-
nously. One of the workarounds, communicating
in unstructured text fields not intended for that
purpose, reveals a poorly supported need to com-
municate across disciplines. It is expected that
having an enhanced ability to communicate would
improve patient safety in general. Specifically,
these findings suggest opportunities for: (1)
asynchronous communications across multiple
disciplines when the person initiating the commu-
nication does not know which specific person or
possibly even discipline needs to receive the com-
munication, (2) synchronous real-time communi-
cations with continuous updates by personnel
representing related but distinct disciplines to
coordinate care activities for a set of patients who
are transitioning in and out of a shared physical
suite of dedicated care spaces, and (3) warning
flags or reminders in a prominent location, similar
to writing on a post-it note on the top of a paper
chart, pushed to all personnel who access informa-
tion about a particular patient. On the other hand,
when communication is hidden, in that a field
needs to be clicked to view the information or a
user is not expecting that content to be contained
in the field, critical information could be missed.
Thus, having more formal support for commuica-
tion that fits well into the workflow as well as
accompanying descriptions in formal policies and
procedures would be helpful.
Minimize adding new steps to workflow with
HIT implementation to minimize workarounds
using unauthorized process steps. With the
BCMA HIT for nurses, there tended to be new
requirements to enhance safety that was not pre-
viously part of the regular workflow. When an
activity is required that did not previously exist,
then it is not surprising that busy professionals
will search for a means to return to prior levels
of workload by reducing the requirements for
the new task.
Clarify organizational priorities during goal
tradeoffs. Some of the workarounds, such as
delaying the entry of data into an electronic
whiteboard, result from delaying one task in the
face of simultaneous competing demands or per-
forming activities in a different sequence than
intended. If competing demands are not priori-
tized in a desired fashion, training interventions
might be useful that emphasize the hierarchy of
organizational priorities during tradeoffs.
Implications for Practice
Based on this review, workarounds related
to HIT have the potential to negatively impact
patient safety. First, the first known study to
correlate the extent of workarounds with the
extent of medication errors was identified,
which provides the first empirical evidence that
some types of workarounds negatively impact
patient safety. Second, it is likely that one type
Workarounds with HIT
of workarounds, unauthorized process steps
conducted to avoid new steps in the workflow,
will be prevalent following the implementation
of new HIT.
These insights suggest three implications for
practice.
Provide summary overview displays to sup-
port individual as well as shared situation
awareness. For situations where information is
dispersed across multiple displays, paper-based
summaries currently provide instant access to
information in one place without requiring a
login or being tied to a physical location with a
computer monitor. Nevertheless, paper-based
systems are at risk of having outdated informa-
tion and are typically not accessible by anyone
but the person who created the summary. There-
fore, having an electronic “at a glance” sum-
mary display that is tailored to the needs of a
particular role, such as a nurse taking care of a
patient, would likely be useful. Having the abil-
ity to print these summaries to support portabil-
ity and individual note-taking to aid memory
would likely be useful for individual situation
awareness support.
Design HIT to explicitly support communica-
tion across roles for specific activities even when
those who receive the communication are not
identified in advance. An implication of these
findings could be that communication can be
more directly supported in the HIT, even in situ-
ations where the specific person within a disci-
pline to receive the communication is not yet
known. Communication that is asynchronous is
likely to be useful and reduce the risk of missing
information. It might be possible to electroni-
cally track and display the status of when and
whom receives intended communications and
acts as expected on that information. In addition,
increasing the ease and access of making minor
real-time updates to publicly displayed informa-
tion, such as is done with manual whiteboards, is
likely to be beneficial in increasing information
accuracy and timeliness in shared physical envi-
ronments. Therefore, electronic whiteboards
could provide similar benefits by using login
strategies such as barcoded ID badges and mobile
views of whiteboard information on a personal
electronic device. Finally, creating shared “post-
it notes” or other shared flags or warnings or
9
reminders upon accessing a patient’s chart by
any user is likely to be a valuable feature.
Reduce the risk to reputation due to potential
electronic monitoring of individual perfor-
mance. Although there could be benefits of
monitoring patterns in timeliness of medication
administration, it is likely prudent to consider
the potential unintended consequences. A pre-
dictable consequence of monitoring activities of
individuals and displaying the analysis of these
activities to administrators is that there is a risk
to reputation. When there is a risk to reputation,
it is likely that gaming behaviors will increase or
monitored activities will be prioritized more
highly than is desirable (Woods & Hollnagel,
2006). On the other hand, there might be legal
requirements or other benefits to capturing the
identity of the nurse that administered the medi-
cation. These tradeoffs will need to be actively
considered for each implementation. An exam-
ple of a compromise position would be to make
transparent to the individual how their perfor-
mance compares against others in the organiza-
tion on demand and to limit access to that data to
a small set of individuals.
Next Steps for Research
This research identified both positive and
negative workarounds. At this time, it is not clear
how to distinguish theoretically between work-
arounds that have the potential for such nega-
tive consequences that they should be actively
discouraged or eliminated, workarounds that
would benefit from transitioning into formal
documentation in policies and procedures and
HIT, and workarounds that are necessary to
allow only for exceptional circumstances as
goals are traded off but should be discouraged
during routine situations. Future research can
clarify how to distinguish between these types
of workarounds.
An important area relates to measurement for
workarounds. As we develop measures for spe-
cific workarounds, the impact of initiatives to
change the rate of workarounds can be objec-
tively measured. As one example, if a nurse is
documented to administer a set of medications
to six patients within a five-minute window,
then it would be likely that the documentation of
administration was done before or following the
10
actual administration event. Similarly, the
impact of potentially deleterious, well-intended
initiatives to eliminate workarounds that fill an
important function, such as removing manual
whiteboards from the emergency department,
could be objectively measured and appropriate
adaptations at the organizational level made in
response to changes in these measures.
In the future, it is likely that there will be
increased interest for health care professionals to
develop or use apps as opposed to locally devel-
oped paper-based systems. In other words, users
will likely be able to use applications or personally
developed software that runs on their personal
electronic devices. Thus, the extent, individualiza-
tion, and complexity of workarounds will likely
increase even further as well as the associated
potential for positive and negative unintended
consequences. One predicted consequence of
these types of workarounds could be an increased
exposure to the risk of cyber-attacks.
Acknowledgment
The author is grateful for constructive comments
on drafts of the paper by David Woods and Emilie
Roth.
This research was supported by an Agency for
Healthcare Research and Quality (AHRQ) grant
(P30HS024379), the Institute for the Design of Envi-
ronments Aligned for Patient Safety (IDEAS4PS)
Center. The views are those of the authors and not
necessarily those of AHRQ.
Key Points
•• Health care professionals employ workarounds
to avoid new additional steps in workflow when
transitioning from a paper-based system to health
information technology.
•• Individuals can support situation awareness by
using highly encoded paper-based summaries of
patients that can be immediately accessed while
working or interacting with others without need-
ing to log in and that are portable.
•• Providing large, dedicated overview displays
similar to manual status whiteboards can support
coordination and allocation of activities for inter-
disciplinary teams in a flexible manner.
•• Designing health information technology to
explicitly support communication across roles for
Month XXXX - Human Factors
specific activities, even when who will receive the
communication is not identified in advance, can
reduce workarounds that co-opt unstructured text
fields for unintended uses.
•• Actions taken to “game” electronic monitoring via
health information technology can be minimized
by reducing the risk to an individual’s reputation,
such as by only reporting performance measures
for groups or limiting access to a small number
of people.
References
Agrawal, A., & Glasser, A. R. (2009). Barcode medication. Admin-
istration implementation in an acute care hospital and lessons
learned. Journal of Healthcare Information Management,
23(4), 24–29.
Alter, S. (2014). Theory of workarounds. Communications of the
Association for Information Systems, 34(55), 1041–1066.
Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended conse-
quences of information technology in health care: The nature
of patient care information system-related errors. Journal of the
American Medical Informatics Association, 11(2), 104–112.
Bardram, J. E., & Houben, S. (2017). Collaborative affordances
of medical records. Computer Supported Cooperative Work,
27, 1–36.
Blaz, J. W., Doig, A. K., Cloyes, K. G., & Staggers, N. (2016).
The hidden lives of nurses’ cognitive artifacts. Applied Clinical
Informatics, 7(3), 832–849.
Clancy, T. R. (2010). Diamonds in the rough: Positive deviance and
complexity. JONA, 40, 53–56.
Cook, R. I., & Woods, D. D. (1996). Special section: Adapting to
new technology in the operating room. Human Factors, 38,
593–613.
Cresswell, K. M., Mozaffar, H., Lee, L., Williams, R., & Sheikh,
A. (2017). Workarounds to hospital electronic prescribing sys-
tems: A qualitative study in English hospitals. BMJ Qual Saf,
26(7), 542–551.
Ebright, P. R., Patterson, E. S., Chalko, B. A., & Render, M. L.
(2003). Understanding the complexity of registered nurse
work in acute care settings. Journal of Nursing Administration,
33(12), 630–638.
Endsley, M. R. (1995). Measurement of situation awareness in
dynamic systems. Human Factors, 37, 65–84.
Espin, S., Lingard, L., Baker, G. R., & Regehr, G. (2006). Persistence
of unsafe practice in everyday work: An exploration of organiza-
tional and psychological factors constraining safety in the oper-
ating room. Quality and Safety in Health Care, 15(3), 165–170.
Flanagan, M. E., Saleem, J. J., Millitello, L. G., Russ, A. L., &
Doebbeling, B. N. (2013). Paper- and computer-based work-
arounds to electronic health record use at three benchmark
institutions. Journal of the American Medical Informatics
Association, 20(e1), e59–e66.
Friedman, A., Crosson, J. C., Howard, J., Clark, E. C., Pellerano,
M., Karsh, B. T., . . . Cohen, D. J. (2013). A typology of elec-
tronic health record workarounds in small-to-medium size
primary care practices. Journal of the American Medical Infor-
matics Association, 21(e1), e78–e83.
Glaser, B. G., & Strauss, A. (1967). The discovery of grounded
theory: Strategies for qualitative research. New York, NY:
Aldine Publishing.
Workarounds with HIT
Goh, J. M., Gao, G., & Agarwal, R. (2011). Evolving work rou-
tines: Adaptive routinization of information technology in
healthcare. Information Systems Research, 22(3), 565–585.
Gorman, J. C., Cooke, N. J., & Amazeen, P. G. (2010). Training
adaptive teams. Human Factors, 52, 295–307.
Greenfield, D., Black, D., Debono, D., Braithwaite, J., Travaglia,
J., Taylor, N., & Lipworth, W. (2017). Applying the theoretical
domains framework to identify barriers and targeted interven-
tions to enhance nurses’ use of electronic medication manage-
ment systems in two Australian hospitals. Implementation
Science, 12(1), 1–13.
Gurses, A. P., Xiao, Y., & Hu, P. (2009). User-designed informa-
tion tools to support communication and care coordination in
a trauma hospital. Journal of Biomedical Informatics, 42(4),
667–677.
Hardmeier, A., Tsourounis, C., Moore, M., Abbott, W. E., & Gug-
lielmo, B. J. (2014). Pediatric medication administration errors
and workflow following implementation of a bar code medi-
cation administration system. Journal for Healthcare Quality,
36(4), 54–63.
Holden, R. J., Rivera-Rodriguez, A. J., Faye, H., Scanlon, M. C.,
& Karsh, B. T. (2013). Automation and adaptation: Nurses’
problem-solving behavior following the implementation of
bar-coded medication administration technology. Cognition,
Technology & Work, 15(3), 283–296.
Hollnagel, E. (2014). Safety-I and safety-II: The past and future of
safety management. London: Ashgate Publishing, Ltd.
Hollnagel, E., Braithwaite, J., & Wears, R. L. (Eds.). (2013). Resil-
ient health care. Aldersgate, UK: Ashgate Publishing, Ltd.
Horsky, J., Drucker, E. A., & Ramelson, H. Z. (2017). Higher accu-
racy of complex medication reconciliation through improved
design of electronic tools. Journal of the American Medi-
cal Informatics Association [Advance online publication].
doi:10.1093/jamia/ocx127
Jones, K. (2004). Mission drift in qualitative research, or moving
toward a systematic review of qualitative studies, moving back
to a more systematic narrative review. Qualitative Report, 9(1),
95–112.
Jones, T. L., Hamilton, P., & Murry, N. (2015). Unfinished nursing
care, missed care, and implicitly rationed care: State of the sci-
ence review. International Journal of Nursing Studies, 52(6),
1121–1137.
Kobayashi, M., Fussell, S. R., Xiao, Y., & Seagull, F. J. (2005).
Work coordination, workflow, and workarounds in a medical
context. In CHI’05 extended abstracts on human factors in
computing systems (pp. 1561–1564). New York, NY: ACM.
Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008).
Workarounds to barcode medication administration systems:
Their occurrences, causes, and threats to patient safety. Jour-
nal of the American Medical Informatics Association, 15(4),
408–423.
Lowry, S. Z., Ramaiah, M., Patterson, E. S., Brick, D., Gurses, A.
P., Ozok, A., . . . Gibbons, M. C. (2014). Integrating electronic
health records into clinical workflow: An application of human
factors modeling methods to ambulatory care. Proceedings of
the International Symposium on Human Factors and Ergo-
nomics in Health Care, 3(1), 170–177.
Mumaw, R. J., Roth, E. M., Vicente, K. J., & Burns, C. M. (2000).
There is more to monitoring a nuclear power plant than meets
the eye. Human Factors, 42, 36–55.
Niazkhani, Z., Pirnejad, H., Berg, M., & Aarts, J. (2009). The
impact of computerized provider order entry systems on inpa-
11
tient clinical workflow: A literature review. Journal of the
American Medical Informatics Association, 16(4), 539–549.
Norman, D. A. (2008). The way I see it: Workarounds and hacks:
The leading edge of innovation. Interactions, 15(4), 47–48.
Novak, L. L. (2012). Finding hidden sources of new work from
BCMA implementation: The value of an organizational rou-
tines perspective. In AMIA Annual Symposium Proceedings
(Vol. 2012, p. 673). Bethesda, MD: American Medical Infor-
matics Association.
Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving
patient safety by identifying side effects from introducing bar
coding in medication administration. Journal of the American
Medical Informatics Association, 9(5), 540–553.
Patterson, E. S., Ebright, P. R., & Saleem, J. J. (2011). Investigating
stacking: How do registered nurses prioritize their activities in
real-time? International Journal of Industrial Ergonomics,
41(4), 389–393.
Patterson, E. S., Rogers, M. L., Chapman, R. J., & Render, M. L.
(2006). Compliance with intended use of bar code medication
administration in acute and long-term care: An observational
study. Human Factors, 48, 15–22.
Patterson, E. S., Rogers, M. L., & Render, M. L. (2004). Fif-
teen best practice recommendations for bar-code medica-
tion administration in the Veterans Health Administration.
The Joint Commission Journal on Quality and Safety, 30(7),
355–365.
Patterson, E. S., Rogers, M. L., Tomolo, A. M., Wears, R. L., &
Tsevat, J. (2010). Comparison of extent of use, information
accuracy, and functions for manual and electronic patient
status boards. International Journal of Medical Informatics,
79(12), 817–823.
Perry, S., & Wears, R. (2012). Underground adaptations: Cases
from health care. Cognition, Technology, & Work, 14, 253–260.
Rack, L. L., Dudjak, L. A., & Wolf, G. A. (2012). Study of nurse
workarounds in a hospital using bar code medication admin-
istration system. Journal of Nursing Care Quality, 27(3),
232–239.
Reason, J. (1990). Human error. Cambridge: Cambridge Univer-
sity Press.
Sarter, N. B., & Woods, D. D. (1995). “How in the world did we
get into that mode?” Mode error and awareness in supervisory
control. Human Factors, 37, 5–19.
Sarter, N. B., Woods, D. D., & Billings, C. E. (1997). Automation
surprises. In G. Salvendy (Ed.), Handbook of human factors
and ergonomics (2nd ed., pp. 1926–1943). New York, NY:
Wiley.
Sitterding, M. C., Ebright, P., Broome, M., Patterson, E. S., &
Wuchner, S. (2014). Situation awareness and interruption han-
dling during medication administration. Western Journal of
Nursing Research, 36(7), 891–916.
Taliercio, V., Schachner, B., Borbolla, D., Luna, D., Villalba, E., &
Quiros, F. (2014). The expectations of nurses about the imple-
mentation of a barcoded medication administration system: A
qualitative study. Studies in Health Technology and Informat-
ics, 205, 191–195.
van der Veen, W., van den Bemt, P. M. L. A., Wouters, H., Bates,
D. W., Twisk, J. W. R., de Gier, J. J., & Taxis, K.; BCMA Study
Group. (2017). Association between workarounds and medi-
cation administration errors in bar-code-assisted medication
administration in hospitals. Journal of the American Medi-
can Informatics Association [Advance online publication].
doi:10.1093/jamia/ocx077
12
Vicente, K. J. (1999). Cognitive work analysis: Toward safe, pro-
ductive, and healthy computer-based work. New York, NY:
CRC Press.
Vicente, K. J., Roth, E. M., & Mumaw, R. J. (2001). How do opera-
tors monitor a complex, dynamic work domain? The impact
of control room technology. International Journal of Human-
Computer Studies, 54(6), 831–856.
Vogelsmeier, A. A., Halbesleben, J. R., & Scott-Cawiezell, J. R.
(2008). Technology implementation and workarounds in the
nursing home. Journal of the American Medical Informatics
Association, 15(1), 114–119.
Wears, R. L., Perry, S. J., Wilson, S., Galliers, J., & Fone, J. (2007).
Emergency department status boards: User-evolved artefacts
for inter-and intra-group coordination. Cognition, Technology
& Work, 9(3), 163–170.
Westbrook, J. I., Coiera, E., Dunsmuir, W. T., Brown, B. M., Kelk,
N., Paoloni, R., & Tran, C. (2010). The impact of interrup-
tions on clinical task completion. BMJ Quality & Safety, 19(4),
284–289.
Woods, D. D. (2006). Essential characteristics of resilience. In
E. Hollnagel, D. D. Woods, & N. C. Leveson (Eds.), Resilience
engineering: Concepts and precepts (pp. 21–34). Aldershot,
UK: Ashgate.
Woods, D. D., & Hollnagel, E. (2006). Joint cognitive systems:
Patterns in cognitive systems engineering. New York, NY:
CRC Press.
Month XXXX - Human Factors
Woods, D. D., & Shattuck, L. G. (2000). Distant supervision-local
action given the potential for surprise. Cognition, Technology
& Work, 2(4), 242–245.
Xiao, Y. (2005). Artifacts and collaborative work in healthcare:
Methodological, theoretical, and technological implications of
the tangible. Journal of Biomedical Informatics, 38(1), 26–33.
Xiao, Y., Kiesler, S., Mackenzie, C. F., Kobayashi, M., Plasters, C.,
Seagull, F. J., & Fussell, S. (2007). Negotiation and conflict in
large scale collaboration: A preliminary field study. Cognition,
Technology & Work, 9(3), 171–176.
Xiao, Y., Lasome, C., Moss, J., Mackenzie, C. F., & Faraj, S. (2001).
Cognitive properties of a whiteboard: A case study in a trauma
centre. In ECSCW 2001 (pp. 259–278). Dordrecht: Springer.
Emily S. Patterson is an associate professor in the Divi-
sion of Health Information Management and Systems,
School of Health and Rehabilitation Sciences, College
of Medicine at The Ohio State University. She obtained
a PhD in integrated and systems engineering in 1999 at
The Ohio State University.
Date received: August 14, 2017
Date accepted: February 8, 2018