Table 4.

Illustrative examples of workarounds

Factors	Studies that provided examples of individually enacted workarounds	Illustrative examples of individually enacted workarounds	Studies that provided examples of collaboratively enacted workarounds	Illustrative example of a collaborative enacted workaround
Technology,Characteristics of the technology that impose workflow blocks/delays	[4,6,34,48,49,51,53,54],[63,68-71,76,77,80-82,84-86]	• In a study examining nurses use of BCMA, nurses were observed to “batch” and pre-pour medications which involves scanning medications and multiple ID bands for multiple patients before commencing medication administration [6]	[4,6,48-50,53,54,56,68,69],[71,76,80-82]	• A study examining use of a CPRS identified a paper-based workaround in which doctors write orders on paper and get the nurses to input them in the CPRS and the doctor signs the nurse-entered orders later [80]
		• In a study examining the use of a CPOE system, dead zones caused the computers to freeze so the nurses used paper lists of pertinent patient information, surgery lists, whiteboards, and other computers to enhance communication and ensure that timely care was given [71]		• There were several workarounds described in a study that compared a paper-based and electronic prescribing system. For example, in the CPOE there was a similarity between the Start and Stop orders which nurses worked around by using a STOP stamp on the paper chart to indicate that the medication should be stopped. Another workaround involved nurses writing new times for administration on the paper Kardex but not entering these new times in the CPOE because nurses were blocked from making changes to orders in the system [50]
		• In a study examining the side effects of BCMA introduction, nurses were observed to workaround scanning wristbands on patients by typing in the 7-digit number because it took less time than wheeling the medication cart into the patient’s room, the patient was isolated, did not have a band on, or the wristband barcode did not scan reliably [84]
Operational failures, exceptions and work restraints, Issues that make it difficult to complete the task: resource and equipment issues; time; illegibility; too much or not enough information; knowledge; others’ actions	[24,35,36,40,44,48,49,57],[59,61,65,66,69,76,78,80],[81,84,85]	• A study examining the universal precaution practices of nurses in an ED, offers several examples of workarounds including nurses re-sheathing needles to workaround the distance to the disposal container and to facilitate dislodging needles from syringes; not wearing gloves to workaround the perceived greater risk of needle stick injury if the gloves were the wrong size [57]	[24,42,48,49,59,61,67,69],[72,74,76,78,80,81]	• A study examining rework and workarounds in hospital medication administration processes reported that when nurses were unable to understand a medication order, they worked around this barrier by asking other nurses’, clerks’, pharmacists’ opinions or make a decision without calling the physician because they did not want to bother or feared repercussions from bothering the physician [61]
		• In examining the relationship between work constraints imposed on nurses and patient falls, nurses were identified to multi task, keeping mental track of where they are up to in their list of tasks (cognitive head data). To work around the constraints of too much cognitive head data, nurses use written and mental chunking schemas (e.g. visual reminders and chunking groups of tasks) [78]
				• A study of the relationship between nurses’ work constraints and patient falls identified that nurses workaround the constraints imposed by a lack of formal handover between registered nurses and assistant nurses by informal querying of the previous care nurse about fall status and use of visual cues e.g. stickers [78]
Rules/policies/guidelines/regulations,Formal rules, policies, guidelines, regulations regarding delivery of care	[4,34-36,40,41,44-46,48,49,57],[61,65,66,68-71,79,82,84,85],[87]	• A study assessing the impact of a CPOE system noted that when physicians had not yet entered medication orders in the system, nurses worked around the delay by beginning medication work based on the notes they took during medical rounds [49]	[4,6,42,48-50,52,56,67,68],[71,75,80,81,84]	• The clinicians work around the policy that requires completion of an authorisation form for a restricted antibiotic to be dispensed [56]
				• Collaboration is needed to work around error reporting by redefining the error. For example, a nurse may be given the medication chart from the day before to fix because she/he forgot to record it on their last shift [42]
		• A study examining baby feeding practices by midwives in 2 UK hospitals, identified that while feeding breast fed babies a bottle of artificial milk was not evidence-based practice and against policy, midwives secretly gave bottles of artificial milk at night, working around espoused policy requirements by calling it a 'special’ cup feed (a cup feed being acceptable to policy) [36]

Legend: BCMA (barcode medication administration); CPOE (Computer Physician Order Entry); CPRS (Computerized Patient Record System); ED (Emergency Department).