Table 5 The potential effects of workarounds in acute care settings for patients, staff and organisation

Positive effects

• Care is delivered according to the patient’s specific needs [42, 67]. For example, ‘batching’ care so that the patient can get a good night sleep; giving medications early so that they won’t be four hours late [42]

• Decrease stress for manager and other staff [42]

• Workarounds may lead to better rules [66]

• Provide excellent information for improvement efforts [81, 82]

• Increase efficiency and support work [76]

• Circumvent barriers to delivering care [56, 67]

• Annotating printed paper patient information sheets rather than only viewing information in EHR, enables clinicians to acquaint themselves more with the patients [53]

Negative effects

• Decrease patient safety by increasing the potential for error [4, 6, 34, 40, 41, 43, 45–49, 51],[61–64, 68–70, 82–87]

• Make staff vulnerable to retribution [37, 39, 44, 66, 67]

• Prevent organisational learning and improvement through hiding problems and practices that are occurring in real time [1, 6, 24, 47, 56, 58, 59, 72]

• Do not accurately reflect patient care delivery (e.g. charting a medication earlier than it was given) [6, 48, 61, 84]

• Time consuming, erode staff time and energy or increase cognitive effort [48, 49, 58, 59, 72, 74, 82]

• Create problems elsewhere in the system and can lead to other workarounds [4, 24, 48, 59, 62, 74]

• Decrease surveillance of patients [72]

• Increase the risk of occupational injuries [79]

• Directly or indirectly cost hospitals money [1, 24, 59]

• Staff work without necessary equipment [72]

• Informal teaching of workarounds is problematic because there is no clarity about what clinicians are being taught [53]

• Loss of information about patients [49, 71, 75, 76, 81]

• Enable staff to express emotion to coordinate and work more effectively [75]

• Contribute to a culture of unsafe practices [40, 62]

• Create new pathways to error [81]

• Potentiate security breaches (e.g. nurses borrowing access codes and posting them for easy viewing) [69]

Both positive and negative effects

• In some instances workarounds enhance patient care but they can also potentiate patient harm [4, 24, 48, 69, 71]

• Workarounds may ease and accelerate performance but increase workload [48]

• Allow the use of CPOE but hide opportunities for redesign and improvement [47]

• Workarounds fix problems so that patient care can continue but in not addressing the underlying problem similar problems may reoccur in relation to patient care [1, 58, 59]

• Help with the coordination of work and reduce cognitive load by providing solutions to recurring problems but lead to unstable, unavailable or unreliable work protocols [74]

• Allow the system to continue functioning but may lead to widespread instability [74]

• While one workaround may prevent medication errors (e.g. using a STOP stamp on the paper medication chart to indicate that a medication has been ceased because the stop and the start orders in the CPOE look very similar) other workarounds using the same system increase error risk (e.g. recording actual administration times on paper medication chart but not in the CPOE) [48–50]

• Fix problems so that patient care can continue but in not addressing the underlying problem similar problems will occur requiring staff to address them again [58, 59]

• Informal handover of information to workaround the lack of formal communication channels reduced falls but may create gaps in passed on patient information [78]

• Workarounds may circumvent problematic EPR-mediated communication between staff but may also create confusion if the workaround is not explained [54]

• Deviations are linked with good patient outcomes (innovations) and bad patient outcomes (errors) [73]