To Hack or Not to Hack? Continued from page 7
In an example of a workaround leading to an improved process, the “brief operative note” necessary in the Post-Anesthesia Care Unit (PACU), and the completed formal operative note for the same routine procedure were combined into one document. With the use of electronic health record capabilities, both the brief and the formal operative notes could be completed and available when the patient arrived in the PACU. This provided all the necessary and required information in an easy-to-read format and completed procedural documentation requirements more quickly than previous processes while eliminating duplication of documentation elements. However, initially this workaround conflicted with organizational policy which described two required documents. To the organization’s credit, the value of the workaround was appreciated, and policies were changed to legitimize this improved process.
the patient safety implications of this situation are clear. However, this example also speaks to the missed opportunity to improve the systemic process by which pharmacy was delivering medications to inpatients. Healthcare technology workarounds are plentiful and also can create hazards. In response to complex login passwords, users may post their password alongside their computer, leading to the potential for a significant data breach. In response to IV pumps with built in “smart technology” which malfunctions or is difficult to program, care teams may bypass the ostensible safety features instead of improving the programming or reporting the malfunction. In all of these situations, workarounds are a way to accomplish work when “work as done” does not achieve the efficiency or functionality of “work as imagined” for designed processes. However, continuing to use a workaround camouflages problematic processes. If leadership is unaware of shortcomings, they won’t allocate resources to fix the problems.
Agreement Workarounds should be viewed as learning opportunities. In one workaround analysis, it was discovered that nurses were unable to use the mandated barcode medication administration system correctly because of a lack of internet connectivity in some patient care areas.11 No amount of “retraining” the nurses would have corrected that underlying problem but studying the workaround and identifying and mitigating a technologic limitation contributed to a more effective remedy. Some workarounds bring to light system shortcomings, others provide potential system improvements. Simulations that replicate patient care processes,12 and interviews conducted with respect for local expertise are among the methods that can be used to discover, develop, and test system improvements. Crucially, the surfacing and studying of workarounds can provide valuable information about how to improve patient care processes. References: 1. Merriam-Webster. (n.d.). Life hack. In Merriam-Webster.com dictionary. Accessed 4 October 2021, from https://www.merriam-webster.com/dictionary/life%20hack 2. Deutsch ES. Workarounds: Trash or Treasure? Pa Patient Saf Advis 2017 Sep;14(3). 3. Brous E. Crisis Standards of Care. Am J Nurs 2021 Jul 1;121(7):51-54. doi: 10.1097/01.NAJ.0000758504.14938.01. 4. Hallal A, Andraos R, Saad GA, Boyajian T, Hoballah J. Mass casualty management during a pandemic surge: The American University of Beirut Medical Center experience. Semin Vasc Surg. 2021 Jun;34(2):51-59. PMID: 34144748 doi: 10.1053/j.semvascsurg.2021.04.005. Epub 2021 May 25. 5. Vincent C, Amalberti R. Safer Healthcare: Strategies for the Real World. 2016. New York, NY: SpringerOpen 6. Chuang S, Woods DD, Ting Hsieh-Wei. Cook RI, Hsu J-C. Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion. Disaster Med Public Health Prep. 2020 Aug;14(4):467-476. PMID: 31439072 doi: 10.1017/dmp.2019.69. Epub 2019 Aug 23. 7. Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Quality & safety in health care. 2005;14:130-4. 8. Tucker AL. Workarounds and resiliency on the front lines of health care. Rockville (MD): Agency for Healthcare Research and Quality; 2009 Aug. 6 p. 9. Top 10 Patient Safety Concerns for Healthcare Organizations 2018. https://www.ecri.org/EmailResources/PSRQ/Top10/2018_PSTop10_ExecutiveBrief.pdf accessed 4 October2021. 10. Brown T. The American Medical System is One Giant Workaround. https://www.nytimes.com/2019/09/05/opinion/hospital-workaround-health-care.html accessed 4 October2021 11. Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. Near-Miss Event Analysis Enhances the Barcode Medication Administration Process. Pa Patient Saf Advis 2017 Dec;14(4). 12. S tone K. Exploring Workarounds: The Role of Simulation to Build Resilience. In Comprehensive Healthcare Simulation: Improving Healthcare Systems. Eds: Deutsch ES, Perry SJ, Gurnaney HG. Springer 2021
8 SOUNDINGS | Fall 2021
