Categories of potential causes of safety standard workarounds, frequency and papers
| Cause | Characteristics | Frequency | Paper(s) |
| Organisational | Staffing levels, training, productivity pressures, workload, organisational climate, leadership, expectation of ability to multitask, information issues, ambiguity of policies, fit and relevance of policies, too many policies and complexity of workplace that impose obstacles to workflow. | 25 papers | 13 29–34 36–38 40–54 |
| Example | ‘Failure to check medications at the bedside and the patient’s identity because this represented the only way to ‘get things done’ and achieve the goal of timely medication administration.’ | 37 | |
| Task factors | Actual or perceived factors that impact on task performance, including factors that slow down performance and impose obstacles to workflow. | 16 papers | 13 29 31 33 36 38 40–42 45 46 49–52 54 |
| Example | ‘Clinicians created workarounds to improve their actual efficiency of accomplishing tasks with the EHR (electronic health record). For example, clinicians knowingly did not re-enter do not resuscitate (DNR) orders in the EHR. Although DNR orders are valid for up to 1 year, the EHR requires clinicians—as a result of the hospital policy—to re-enter DNR orders every time a patient is readmitted to the hospital. In several cases, patients were readmitted every week on a routine basis. However, clinicians considered re-entering DNR orders for such patients on a weekly basis a ‘waste of time’ and therefore only entered a DNR order once.’ | 13 | |
| Patient factors | Acting in the best interest of patients based on their individual clinical presentation or specific circumstances that impose obstacles to workflow. | 16 papers | 29 34–36 38 40 41 43 45–48 50 52–54 |
| Example | ‘It is a ‘requirement’ that if a patient is to be given pain relievers a clinical judgement should be based on a VAS pain score (visual analogue score). If the nurse is confronted with a patient who does not want to be measured in this way (he is angry or uncooperative for some reason), or if he cannot respond (due to dementia), then the nurse has to justify her reasons for not using the standardised score to determine what pain relief to administer.’ ‘In the observed scenario, ‘despite the patient denying the nurse the opportunity to use this technology, she still needs to relate to the patient’s reaction to it and to his pain and engage with his situation. She works around the technology by observing him and communicating with him in a different way (without using the VAS scale) and, when documenting her work in the nurse’s office, she spends extra time documenting her non-standard work.’’ | 34 | |
| Individual clinician factors | Factors related to the individual clinician, such as fatigue, cognitive load, age, preference, position, proficiency, experience, familiarity with person or task, that impose obstacles to workflow. | 16 papers | 13 30–33 35–37 40–42 44 45 48 53 54 |
| Example | ‘Individual practices had unwritten well understood processes for contacting patients which were generally used and justified in different ways.’ | 35 | |
| Professional factors | Factors related to professional judgement, professional boundaries and professional standards that impose obstacles to workflow. | 14 papers | 13 29–32 34 38 40 47–52 |
| Example | ‘Dispensing controlled drugs that have passed their expiry date for a patient in urgent need of end of life care.’ | 38 | |
| Environmental factors | Factors related to the physical structure of the environment (space, light, heat) and the location of people and equipment that impose obstacles to workflow. | 12 papers | 29 30 38 41–43 45 47 49 51 52 54 |
| Example | ‘The small size patient drawer led to deviations such as not dispensing the medications because only small forms of oral medications and ampoules were dispensed in the patient drawer, whereas voluminous medications were retrieved during administration.’ | 42 | |
| Relational/team factors | Factors related to teamwork, including managing hierarchy, communication issues, avoiding confrontation, delegation of responsibilities, that impose obstacles to workflow. | 11 papers | 29–32 35 37 41 43 49 51 52 |
| Example | ‘A fellow resident advised her to ‘just avoid her as much as possible’… However, they seek to make things work as well as possible by taking a lifeworld approach, deviating from the rules, while still using part of the system by way of creating workarounds such as informing a supervisor only after something has taken place.’ | 32 | |
| Technical factors | Actual and perceived hardware and software issues that impose obstacles to workflow. | 7 papers | 13 31 42 46 49 51 54 |
| Example | ‘I needed to administer medications without scanning the patient wristband…because of scanner failure.’ | 46 | |
Most papers described multiple causes of workarounds rather than just one cause.