DDHA 8601 Week 1 Workaround Discussion Post Example

Week 1 Discussion: Why Staff Work Around Technology

Passed Every Acceptance Test, Routed Around by Week Three: Why a Teaching Clinic's Schedulers Went Back to a Paper List

The new scheduling system at our teaching clinic was never rejected; it was routed around, and the reasons sit in the work rather than in the software. The clinic is a composite internal medicine practice where 36 residents see patients under faculty supervision. The system passed every acceptance test the vendor and our information technology team ran. Three weeks after go-live, the front desk was keeping a handwritten list on a clipboard, and by the second month that list held most of the clinic's urgent follow-up bookings.

The first piece of evidence is what schedulers did with patients discharged from the hospital who needed a visit within seven days. The system releases resident appointment templates four weeks ahead, built from the residents' rotation calendar. Rotations change monthly, and the calendar is often finalized late, so the slots a discharged patient needed frequently did not yet exist in the system. Schedulers wrote these patients on the clipboard and booked them by hand once a slot appeared, sometimes calling the patient twice. Koppel et al. (2008), studying workarounds to bar-code medication systems, found that workarounds most often arose where the technology's assumptions did not match the actual sequence of work, and this is a clean example: the system assumed the calendar would exist before demand did.

The second is what the charge nurse did about supervision. First-year residents may see patients only when a supervising physician is in the clinic. The system had no field for preceptor presence, so it would happily book a first-year resident into a slot with no supervisor. The charge nurse began marking the paper schedule each morning with which slots were safe, and schedulers checked the paper before trusting the screen. Debono et al. (2013), in a review of nurses' workarounds, describe them as a response to blocks in the flow of work that also protect patients, which is how staff here described this one in their own actions: they did not complain about the system, they simply stopped relying on it for this decision. Greenhalgh et al. (2017) warn that technologies often fail not at adoption but afterward, through quiet abandonment when they do not fit the complexity of the work.

The paper list will stop being useful when the system can hold slots tied to a named preceptor's presence and release them within three days rather than four weeks.

Reply to Tamsin

Tamsin, you described your hospital's new bed-board as a failure because nurses still phone bed management, and you concluded that training was the problem. Your own account suggests otherwise. You wrote that the bed-board shows a bed as clean when environmental services marks it, but nurses phone to ask whether the room has also been restocked, which the board does not track. That is the same pattern as our clipboard: the work contains a step the system does not represent. Koppel et al. (2008) found that more training rarely removes a workaround whose cause is a mismatch between the technology and the task. Would adding a restocking status end the calls?

Reply to Obinna

Obinna, I agree that the electronic sign-out tool on your unit was worked around, but I would question your view that the workaround is harmless. Residents on your unit keep a parallel paper sign-out because the tool truncates long problem lists. That protects patients during the shift, but it also means the electronic record of handoffs is incomplete, and anyone auditing a missed task later will find a record that does not reflect what was said. Debono et al. (2013) note that workarounds can protect patients in the moment while creating risks elsewhere. The question for your leaders may be whether to fix the truncation or to accept paper as the record.

References

Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses' workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13, Article 175. https://doi.org/10.1186/1472-6963-13-175

Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A'Court, C., Hinder, S., Fahy, N., Procter, R., & Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research, 19(11), Article e367. https://doi.org/10.2196/jmir.8775

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. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616