HLTH 4110 Week 7 Human Factors Workaround Note Example

Memorandum

To: Nurse Manager, 5 West; Pharmacy and Nursing Informatics

From: Quality and safety student analyst

Date: Month Day, Year

Re: Three workarounds observed during mealtime insulin on 5 West, read as evidence about the system's design, with design questions for each

Purpose

During four observed breakfast medication passes on 5 West, I recorded three workarounds that nurses use around mealtime insulin. Each one departs from policy, and each one is common enough that staff describe it as normal. This note reads them as evidence about the design of the work rather than about the people doing it, using a work system view in which outcomes come from the interaction of people, tasks, tools, environment and organization (Carayon et al., 2006). The observations are a composite drawn for this assignment.

Workaround 1: Scanning the Spare Label

What happens. Several nurses carry a sheet of spare patient identification labels on the medication cart and scan the sheet rather than the patient's wristband. Why. Wristband barcodes on curved, creased bands often fail to scan, the rooms are dim before 0800 and patients are asleep. A failed scan takes several tries and wakes the patient. What it costs. The scan exists to confirm that this dose is going to this patient; scanning a label at the cart confirms only that the nurse has the right sheet. A study of barcode systems in several hospitals found that scanning substitute labels was among the most common workarounds, and that most workarounds traced back to problems with the technology, the task or the setting (Koppel et al., 2008).

Workaround 2: The Paper Insulin List

What happens. Most nurses keep a handwritten list of their patients' insulin doses, last glucose and meal status, folded in a pocket. Why. The medication screen shows the scheduled dose but not whether a tray has arrived, whether the patient ate or whether a test will keep the patient from eating; that information sits on three other screens and in the dietary office. The paper list puts it in one place. What it costs. The list is only as current as the last time it was updated, it is not visible to anyone else and it does not change when an order changes overnight, which is how the NPO status in the earlier event was missed.

Workaround 3: Clicking Through the NPO Banner

What happens. When a nurse scans a medication for a patient ordered nothing by mouth, a banner appears requiring acknowledgment. Nurses acknowledge it in about a second without reading. Why. The banner appears for every medication for every NPO patient, including intravenous drugs and medications allowed with sips of water, so on a typical morning a nurse may see it a dozen times when it does not apply. What it costs. When the banner does matter, as it did with mealtime insulin, it looks identical to the dozen times it did not. Research on prescribing alerts found that clinicians override most of them, and that overrides rise when alerts are frequent and often irrelevant (van der Sijs et al., 2006).

What the Workarounds Have in Common

Each workaround fills a gap between how the system was designed and how the work arrives. The scanner was designed for well-lit rooms and flat bands. The medication screen was designed around clock times, not meals. The banner was designed to warn about NPO status without asking which medications NPO status affects. In each case nurses invented a cheaper path, and in each case the cheaper path removes a safeguard the designers intended. Removing the workarounds by policy, without changing the design, would put the original costs back on nurses, and new workarounds would likely appear.

Design Questions

For informatics and the scanner vendor: Can wristbands be printed with a flat tab or a larger code, and can handheld scanners be tested in dim light at the bedside?

For informatics and pharmacy: Can the medication screen show meal status and planned tests alongside mealtime insulin, so the nurse sees in one place whether the patient will eat?

For informatics: Can the NPO banner fire only for medications that NPO status affects, such as oral drugs and mealtime insulin, so that it appears rarely and means something when it does?

For the nurse manager: Can staff who use the workarounds be invited to test any redesign before it goes live? They know the gaps better than anyone.

None of these questions asks nurses to stop a workaround first. Each asks whether the reason for it can be removed, after which the workaround should fade on its own and any that remain will point to the next gap in the design.

What This Note Does Not Claim

Four observed breakfast passes on one unit cannot show how often each workaround happens across the hospital or whether any has caused harm beyond the event studied earlier. The note also does not judge the nurses involved; every nurse observed was trying to give the right dose to the right patient on time, and the workarounds were their way of doing that with the tools available. A short follow-up count, done by a charge nurse on one week of mornings, would show how widespread each one is before any redesign is funded.

References

Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl. 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

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

van der Sijs, H., Aarts, J., Vulto, A., & Berg, M. (2006). Overriding of drug safety alerts in computerized physician order entry. Journal of the American Medical Informatics Association, 13(2), 138-147. https://doi.org/10.1197/jamia.M1809