Elderly/Long-term Care

Researchers examine the relationship of workarounds to technology implementation and medication safety in nursing homes

As many as 42 percent of adverse drug events in nursing homes are preventable. One way to reduce these errors is through the implementation of technology in the systems of medication administration. This technology, however, sometimes causes blocks in the work flow (e.g., through safety alerts and requests for more documentation). When nursing home staff work around these blocks, new types of medical errors and unintended consequences are introduced. A new study provides practical examples of workarounds in the nursing home and examines the risks to medication safety.

Researchers observed five Midwestern nursing homes that had implemented a fully integrated electronic health record (EHR) and an electronic medication record (eMAR). The medication administration system was mapped before the technology was implemented and then six months after implementation.

The authors identified two distinct root causes for workarounds. First were those introduced by the technology itself. For example, intentional blocks were designed in the system to prevent the ordering of excessive medication, but staff often worked around this block by entering several smaller doses of the same medication to obtain the full order.

Unintentional blocks were also evident; for instance, slow wireless connections when viewing multiple screens of a patient's health record led frustrated staff to consult written notes instead. A second root cause of workarounds was the failure to reengineer related processes for technology. For example, staff bypassed safety features that they perceived to be time consuming, such as a double documentation check at the time when medication was prepared and again when administered.

Nursing home staff most often engaged in first-order problem solving when they bypassed blocks in their work flow. That is, they found the most immediate solution to getting past the block. But a more effective and sophisticated approach is second-order problem solving, which addresses the root causes of the blocks. This strategy can be enhanced by the presence of the medication safety team, as well as by encouraging open communication among the staff so that they can talk openly about the blocks they face. Workarounds, such as overriding alerts, are a particular concern for patient safety. This study was supported in part by the Agency for Healthcare Research and Quality (HS14281).

More details are in "Technology implementation and workarounds in the nursing home," by Amy A. Vogelsmeier, M.S.N., R.N., Jonathon R. B. Halbesleben, Ph.D., Jill R. Scott-Cawiezell, R.N., Ph.D., in the January/February 2008 Journal of the American Medical Informatics Association 15(1), pp. 114-119.

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