ETHICS COLUMN 2.0 ANCC Contact Hours Workarounds in the Workplace A Second Look

Jennifer B. Seaman ▼ Judith A. Erlen

Nursing workarounds have garnered increased attention from the protocol established by the organization over the past 15 years, corresponding with an increased (Debono et al., 2013 ). While these behaviors are ob- focus on patient safety and evidence-based practice and served across the spectrum of professions and work- a rise in the use of health information technologies (HITs). place environments, this article focuses on issues that Workarounds have typically been viewed as deviations from occur because of workarounds performed by nurses in best practice that put patients at risk for poor outcomes. the course of patient care. Published work chiefl y por- trays workarounds as negative behaviors and However, this narrow view fails to take into consideration examples of poor nursing practice that need to be elimi- the multifactorial origins of workarounds. The authors ex- nated, as they increase the risk for poor patient out- plore the ways in which evidence-based protocols and HIT, comes. Healthcare providers who engage in worka- designed to improve patient safety and quality, can have rounds are described as “noncompliant” and “risking an unintended consequence of increasing the likelihood of patient safety” ( Debono et al., 2013 ). However, these nurses engaging in workarounds. The article also examines characterizations fail to consider that workarounds are workarounds considering the ethical obligations of both frequently undertaken to ensure patient safety and well- nurses and administrative leaders to optimize patient safety being and provide effi cient care, as demonstrated in and quality. Michael’s case. To view all workarounds as inappropri- ate is an oversimplifi cation of the phenomenon; casting Michael is a with a baccalaureate de- those who engage in them in a negative light is ethically gree who began working 3 years ago at a hospital that problematic. Because there is an increased focus on was part of a large health system. Last month, he was nursing workarounds in clinical practice, a more nu- transferred to another hospital within the health sys- anced exploration of this topic is needed. tem to take a job in a specialty ICU. The health system Workarounds have existed throughout modern nurs- has an integrated, enterprise-wide health information ing but have gained more attention in the last 5 years. system, so that all hospitals within the health system An example of an early, low-tech workaround is the share the same basic electronic ordering, charting, “homemade” warm compress composed of hot towels and medication administration systems. In many wrapped and taped in an underbed pad that was used ways, this made the transition easier, because he was familiar with the various technological applications. temporarily while waiting for the K-pad unit to arrive However, one problem he encountered was that he from central supply. Since that time, the use of worka- was unable to print laboratory specimen labels with rounds has expanded to meet the needs of a complex, his user-ID and password, although he was able to ex- changing clinical environment. Debono et al. (2013) un- ecute all the other functions like order entry, clinical dertook a scoping review of the published literature on charting, and medication administration. As a worka- nursing workarounds in the fi elds of nursing, healthcare, round, Michael has another nurse or his preceptor safety science, and sociology. Although only 251 articles enter her user-ID and password to print out the labels. on the topic were published in the years 1961 to 1999 However, Michael expresses discomfort with this so- (about seven per year), there were 517 articles on work- lution, because it is another nurse’s name that is at- arounds published between 2008 and 2012, correspond- tached to the blood draw or specimen collection in the electronic record. Despite multiple calls to the IT ing to a rate of about 130 per year. What factors led to help center, the problem remains unsolved. Michael would prefer not to use this workaround but is not sure what other options he has available at present. Jennifer B. Seaman, PhD, RN , Post-Doctoral Fellow (T32 HL007820), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. he incident described earlier is commonly re- Judith A. Erlen, PhD, RN, FAAN , Professor and Chair, Department of ferred to as a workaround. A workaround is de- Health and Community Systems, University of Pittsburgh, Pittsburgh, PA. fi ned as an action that is performed by an indi- The authors and planners have disclosed that there are no confl icts of vidual to circumvent a block in workfl ow and interest, fi nancial or otherwise. Tthereby achieve a desired goal; yet, the action deviates DOI: 10.1097/NOR.0000000000000161

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OONJ799_LRNJ799_LR 235235 110/07/150/07/15 5:085:08 PMPM this exponential increase in interest? This heightened application of technology in healthcare gained momen- interest is possibly the result of multiple forces in the tum and expanded into the clinical care dimension. social, technological, and healthcare environments. Highly error-prone clinical care tasks, such as the order- Exploring these simultaneous and pivotal changes that ing, dispensing, and administration of medications, have had an impact on the care delivery environment were obvious targets for systems-level applications of will aid in better understanding nursing workarounds technological solutions. The result was the development and their ethical implications. of large integrated systems, including computerized provider order entry (CPOE), automated medication dispensing, electronic medication administration re- Patient Safety and Evidence-Based cords, and barcode medication administration (BCMA) Practice applications. Similar systems for laboratory specimens The increased interest in nursing workarounds is closely were implemented, with CPOE and automated label related to the rise of the patient safely and quality “move- printing, specimen processing, and results posting. ment” and the advent of evidence-based practice (EBP) Once these systems were in place, they were expected standards. Monitoring of patient outcomes in the 1990s to eliminate (or nearly eliminate) the possibility of med- revealed that many patient injuries and deaths were pre- ication errors. Computerized provider order entry offers ventable. Perhaps the most widely recognized call for ac- real-time alerts to the provider, signaling an allergy, du- tion was the 1999 Institute of Medicine (IOM, 2000) report, plicate order, drug–drug interaction, or an out-of-range To Err Is Human: Building a Safer Health System (2000). dose ( Classen, Avery, & Bates, 2007 ). Computerized pro- Although early work in the fi eld of quality improvement vider order entry also puts to rest the perennial problem focused on increasing the knowledge and critical thinking of interpreting illegible orders. Electronic pharmacist skills of the individual clinician to reduce the number of verifi cation and automated dispensing further ensure unintentional errors, the IOM report recognized the role of that the correct medication, dosage, and form are deliv- system-level factors. This report called for systems-level ered to the nurse. Barcode medication administration interventions to reduce unintentional errors and poor clin- theoretically closes the loop by ensuring that the 5-Rights ical practice and thereby improve patient outcomes. of medication administration are achieved. However, Simultaneously the body of nursing knowledge con- many clinicians report that they have just traded one set tinued to expand and technological tools for rapid in- of problems (risk for human error) for another (burden formation dissemination became widely available. The of ineffi cient and unreliable technology). In fact, a re- available data on a clinical topic could be gathered, cent study by Westphal, Lancaster, and Park (2014) re- analyzed, and synthesized to determine which inter- vealed that along with infection control activities, medi- ventions resulted in the best patient outcomes. This cation administration tasks were the clinical activities technological capability, combined with the motivation most commonly associated with workarounds. to utilize research to improve patient outcomes, led to the development of the EBP model ( Melnyk & Fineout- Problems of Complexity and Overholt, 2005). Once a “best practice” was identifi ed, it was operationalized in a protocol that was imple- Technology mented across a practice environment. Evidence-based Protocols coupled with technology-based systems such protocols were seen as the ideal vehicles with which to as BCMA or CPOE were designed to embed the ele- standardize practice and address the patient safety and ments of best practice into workfl ow and are now the quality concerns at the systems level. Subsequently, ev- dominant model in promoting healthcare quality. This idence-based protocols were widely disseminated approach to improving patient safety and quality, how- across practice environments and the principles of evi- ever, has several limitations. For example, these proto- dence-based healthcare as a model for practice began cols fail to consider the full defi nition of EBP, often do to be integrated into clinical education curricula. These not address the workfl ow issues that are commonly at principles included the importance of basing clinical the root of quality issues, and assume that technological practice on available research fi ndings, learning how to applications are reliable and easily integrated into the locate and critically appraise research, and the need to clinical environment. systematically evaluate the effects of practice change Evidence-based practice, by defi nition, incorporates on patient outcomes (Melnyk & Fineout-Overholt, individual patient values and preferences ( Melnyk & 2005 ). Fineout-Overholt, 2005 ). If the protocols or technology- based systems do not permit the tailoring of practice to accommodate these preferences, the nurse devises a Rise of Health Information workaround to achieve patient-centered care. One ex- ample of this is standard medication administration Technology and Healthcare times. When the physician enters an order for a medica- Informatics tion, it is automatically scheduled for a specifi c time. The rapid proliferation of health information technol- The times may be completely arbitrary, but this practice ogy (HIT) and the increased availability of searchable allows for effi cient automated dispensing and is based electronic databases made it possible for nurse re- on recommendations from pharmacy and HIT govern- searchers, clinical nurse specialists, and clinical work- ing bodies ( Vermeulen et al., 2007 ). If the patient prefers groups to gather, synthesize, and translate large vol- to take the medication at a different time (and there is umes of research into EBP protocols. In addition, the no clinical contraindication for it), the nurse has to

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OONJ799_LRNJ799_LR 236236 110/07/150/07/15 5:085:08 PMPM attempt to have the medication rescheduled or engage erable nursing time ( Halbesleben, Savage, Wakefi eld, & in a workaround. Such a workaround might be charting Wakefi eld, 2010). Alternatively, the nurse may choose to that the medication was given, but then giving it at a affi x a generic label, with the patient name and identifi - later time. If the system were designed with the fl exibil- ers, but this alternative has implications too; in auto- ity to support reasonable variations of a clinical process, mated laboratory systems, that specimen will need to be the need to resort to a workaround would be lessened. manually processed. Clearly, increased automation and Second, the implementation of technology-based integration demand increasingly high levels of techno- systems alone cannot overcome the workfl ow issues in- logical reliability or workarounds are inevitable! herent in complex care environments. If systems merely Proponents of the technology may say, “Well, at automate ineffi cient, error-prone processes, the results least patient safety was maintained—and that’s the even with seamless technology will not overcome the most important thing.” But poor technological relia- root causes of error and poor quality. Rather, worka- bility and a lack of robust systems come with a cost, rounds will be necessary. For example, consider the specifi cally, the impact on staff morale and sense of challenge of providing discharge medication instruc- professionalism. Furthermore, in instances such as tions to outpatient surgery patients. These patients are the one described previously, there is the need to con- referred by their primary care providers (PCPs) to spe- sider the tasks that the nurse was unable to complete cialists for evaluation and possible surgical interven- while he was fi xing the label printer. A qualitative tion. If surgery is recommended and chosen, the patient study by Westphal et al. (2014) of workarounds ob- is admitted under the care of the surgeon and dis- served by 4th-year nursing students showed time pres- charged by the surgeon, who must provide detailed dis- sures to be a major force behind engagement in work- charge instructions, including instructions regarding arounds. A survey by Rack and colleagues on BCMA medications. If a medication was stopped prior to sur- workarounds revealed that greater than half of nurses gery, the surgeon has to give detailed instructions about polled stated they had encountered at least one situa- restarting it. If a new medication is needed, the surgeon tion in their last shift worked , where they were unable has to prescribe it, ensuring that it is compatible with to scan either the medication barcode or the patient the other medications the patient already takes. Without wristband per the BCMA protocol ( Rack, Dudjak, & the coordinated expertise of both the PCP and the sur- Wolf, 2012 ). These incidents represent situations geon, the process is highly error-prone. Merely automat- where nurses faced diffi culties using the system as de- ing an error prone process (i.e., providing customized signed. For nurses already experiencing time pres- printed discharge instructions instead of hand-written sures, such situations often lead to frustration and ones) will not overcome the problem. Workarounds even greater use of workarounds (Halbesleben et al., such as instructing the patient to “follow up with the 2010; Institute for Safe Medication Practice, 2014; PCP regarding medications” or “resume pre-op medica- Rathert, Williams, Lawrence, & Halbesleben, 2012 ). tions” abound. A new and better process, one that in- Consider the following: cludes a mechanism for obtaining input from both the PCP and the surgeon is needed, especially for patients Nurses describe the intense scrutiny around BCMA with complex medication regimens. Health information scanning reports. Typically reports are generated technology experts point out that the transition to a new daily, and nurses whose scanning percentages fall technology presents organizations with the ideal oppor- below the threshold are subject to progressive disci- plinary action. One nurse described how medication tunity to evaluate current state workfl ow and design a package barcodes often became wet, and would not better, safer future state workfl ow, leveraging the new scan. To avoid manually entering that the medication technology for optimal benefi t. was given (as opposed to scanning it), the nurse The last limitation, the reliability of technological would look to see if another dose of the medication systems, is perhaps the most problematic. With fully au- was present in the patient drawer. If so, she would tomated and integrated systems that incorporate tech- scan the intact medication package, but give the nology in all aspects of a process (e.g., medication or- medication from the damaged package (which may dering, dispensing, and administration; or laboratory or may not have been the correct medication or dose, test ordering, specimen collection, and reporting re- as there was no electronic means of verifi cation). sults), there are multiple points in the process where This is an excellent example of a system without breakdowns can occur. For example, if a laboratory test the necessary redundancy to compensate for a fre- is ordered, a specimen label with patient identifi cation quent technological failure, and short of going to the and order information is printed on the nursing unit. pharmacy to obtain a replacement pill, the nurse has However, if the printer is out of labels or it jams, no label few options. On the contrary, consider an example of is generated. The nurse knows that the laboratory test is a system that was robust to common technological ordered but does not have a label. Depending upon the failure. robustness (built in fl exibility and redundancy) of the system, the nurse may be able to reload or fi x the printer and then reprint the label. However, if this is not the The nursing units used bedside glucometers which had scanning functionality. When performing a blood case, the nurse considers a workaround. Another possi- glucose reading, the clinician scanned the barcode on bility may be to reenter the order and generate a new the patient wristband, performed the test, and the re- label, but then the old order will need to be cancelled, sults were automatically posted to the patient’s elec- especially if the billing system is tied to the ordering sys- tronic record once the glucometer was returned to its tem. This action is termed “rework” and entails consid- docking station. When performing blood glucose

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OONJ799_LRNJ799_LR 237237 110/07/150/07/15 5:085:08 PMPM testing, clinicians frequently encountered diffi culties when scanning patient wristbands. However, in the Examining Workarounds From event of barcode scanning failure, the clinician had Social, Legal, and Ethical the option to manually enter the patient’s ID number Perspectives twice (as a double check) and proceed with testing. When considering the ethical implications of nurse workarounds, there is a temptation to think about them Although manual entry was more time consuming only from the perspective of the nurse and the nurse’s than scanning, it did not require the clinician to leave the obligation legally and ethically to follow prescribed pro- patient bedside, workfl ow was not signifi cantly impeded, tocols and uphold the interests of the patient. Yet, it is and patient safety was maintained. As seen in the fi rst important (and illuminating) to also consider the ethi- example, when systems do not have the necessary capac- cal obligations of healthcare organizations. First, con- ity to compensate for common failures, and leadership sidering the motivations of heath care organizations to treats deviations as “violations,” the result is the perpetu- adopt EBP protocols and the technological applications ation of workarounds. Workarounds were used to keep in which they are embedded may be helpful. From a scanning compliance high, but actual patient safety was legal perspective, healthcare agencies have an incentive not enhanced. to institute technologies to safeguard patient safety. If Beyond the contribution to nurses’ frustration and an adverse event occurs and legal action is taken, the feelings of time pressure, situations that lead to work- institution can argue that it had taken reasonable pre- arounds may possibly contribute to moral distress. cautions to combat that type of error. Moral distress, a concept fi rst described by Jameton Second, there are commercial incentives to imple- (1984) , refers to the experience of stress resulting menting such technologies. Organizations such as The from the inability to act in a manner consistent with Leapfrog Group, a coalition of healthcare purchasers one’s beliefs, due to institutional constraints. The def- dedicated to improving patient safety (The Leapfrog inition was later broadened to include stress symp- Group, 2014 ), score institutions on a set of quality meas- toms resulting from situations where the healthcare ures (including CPOE implementation) and publish provider feels “he or she is not able to preserve all in- these scores on their website. Organizations and corpo- terests and values at stake” ( Kälvemark, Höglund, rations looking to purchase group insurance for their Hansson, Westerholm, & Arnetz, 2004 ). This defi ni- employees use tools like the Leapfrog website to view tion captures eloquently the situation of the nurse different hospitals’ scores on safety and quality meas- who is deliberating whether to employ a workaround ures when selecting a healthcare plan. In a market to expedite care. where institutions compete for customers (individual, Musto et al. (2015) cite that the increased emphasis organizational, and corporate), endorsement by such an on cost-effectiveness and effi ciency in healthcare has organization such as Leapfrog can offer a competitive heightened the tension between corporate and profes- advantage. sional values, and thereby increased the likelihood for In addition, there are fi nancial incentives to imple- moral distress among healthcare providers. While menting technological systems designed to improve pa- some readers might think the idea of moral distress an tient safety. The Centers for Medicare & Medicaid overreaction, it is important to consider both the po- Services has developed an EHR Incentives Program, tential impact of the workarounds used and the fre- which offers healthcare institutions fi nancial compen- quency with which they are employed. While individ- sation if they “adopt, implement, upgrade or demon- ual workarounds may not represent serious ethical strate meaningful use of certifi ed EHR technology” dilemmas, they occur with such frequency (Rack et al., (Health IT.gov, 2014 ). However, this program is only 2012 ; Westphal et al., 2014) that to ignore their re- currently funded through 2016, so there is pressure for peated impact is ethically questionable (Jameton, healthcare institutions to meet the objectives within 1984). Research on the concept of moral distress has that timeframe to achieve maximum compensation. demonstrated a relationship between moral distress, Because some meaningful use objectives are not easily the practice environment, and quality and safety ini- inserted into current clinical workfl ow, institutions may tiatives (Pauly et al., 2012). Moreover, increased levels offl oad EHR tasks to the clinician group that is easiest of moral distress have been associated with nurse to engage. For example, nurses may be asked to com- burnout and workforce attrition. It is vital that institu- plete the cause of death in the EHR, although they may tions consider the degree to which infl exible protocols not be the most appropriate healthcare providers for and technological systems can potentially lead to the task. Ironically, this type of action is itself a worka- moral distress among nurses. round used by institutions to meet requirements, with- Evidence-based practice has great potential to out actually achieving the purpose of the required ob- identify the most effective care, and technological ap- jective. Like the scenario with outpatient surgery plications can improve the safety and quality of care discharge medication instructions, the example high- delivery, but these tools need to be thoughtfully imple- lights the lack of an underlying process; the tension mented to avoid creating rigid and ineffi cient systems caused by competing institutional and professional val- that invite the use of workarounds and potentially ues has the potential to contribute to moral distress lead to moral distress. Given the often imperfect state among nurses. of healthcare systems and the prevalence of worka- Beyond federal fi nancial incentives, HIT vendors also rounds, what are the ethical and legal obligations of advertise that, along with safety and quality benefi ts, ap- the parties involved? plications such as CPOE have been shown to decrease

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OONJ799_LRNJ799_LR 238238 110/07/150/07/15 5:085:08 PMPM costs (Classen et al., 2007). Furthermore, individual in- instructed in the process that was developed for the surance providers may institute pay-for-performance task. Implementation of HIT often affords institutions programs to encourage adoption of certain technologi- the opportunity to optimize workfl ow and create better, cal applications. more effi cient processes using the new technology. But Finally, there are strong social pressures to adopt if end-users are not taught both the new process and technological applications; consumers and healthcare the technology that supports it, they are likely to be providers alike have come to expect the increased use of frustrated and attempt to use workarounds. This con- technology in healthcare and typically equate it with cept is not new—recall the questions encountered when progress and improvement ( Hofmann, 2002 ; Storch, institutions adopt new chest-drainage systems, “Where 2005 ). However, technology alone does not constitute do I put in the water?” A multidisciplinary, multilevel improvement; it must be thoughtfully situated and ap- team approach that fully integrates the people, pro- plied within the larger context of care delivery. Storch cesses, and technology for a given component of care (2005) has challenged healthcare professionals to avoid delivery can anticipate potential workarounds before automatically equating technology and effi ciency with deployment and thereby prevent future situations that improved safety. lead to workarounds. Taken together, these incentives illustrate powerful reasons for healthcare organizations to implement tech- nological systems intended to enhance patient safety Ethically Informed Problem Solving and quality and yet constitute a signifi cant confl ict of Clearly workarounds are multifactorial and are the re- interest. It is easy to see how an organization’s adminis- sult of complex work environments and highly variable tration might push the implementation of a given tech- patient situations. Recognizing that workarounds poten- nology forward to reap certain benefi ts, without thor- tially impact both patients and the nurses who care for ough planning and comprehensive testing. This can them is important. Obviously, prevention is the best result in undue burden on the nursing staff and de- strategy to preempting the need for staff to engage in creased time spent in direct patient care without the workarounds. But beyond prevention, perhaps the best desired gains in patient safety. The ideal model for im- approach to evaluating workarounds is to consider the plementation of HIT includes engagement by the organ- precipitating factors ( Clarke, Lerner, & Marella, 2007 ) ization’s administrative and clinical leadership in artic- and commit the necessary resources to ensure success- ulating the future state vision for technology and ful work redesign. For hospitals, this may entail having a ongoing involvement of both in the design, implementa- nursing informatics (or clinical informatics) staff liaison tion, and support of the system. If the organization’s ad- who is available to come to the nursing unit to trouble- ministration is not committed to providing ongoing re- shoot problems. This individual, if unable to solve the sources to address technological failures, workarounds problem, can serve as a liaison to the IT staff and triage that can undermine patient safety and staff morale will problems based on their relative safety/quality impact. ensue. Michael, the nurse described in the opening vignette, An institution’s leaders are ethically obligated, just as could defi nitely have benefi tted from a resource such as individual healthcare providers, to consider the inten- this. For non-HIT-related problems, such as the outpa- tions of their actions—is a protocol or application being tient discharge instructions, an interdisciplinary team adopted because the leadership truly believes it will im- approach is likely needed. In fact, solutions that incorpo- prove patient safety or because it will yield other gains? rate multiple levels of staff and administration have been Have leaders done due diligence by fully assessing and found to be most effective in reducing moral distress and preparing for the proposed change? In addition to con- are vitally important in care environments with recur- sidering their intentions, organizational leaders are also ring waves of organizational change (Musto et al., 2015). obligated to minimize the possibility of moral distress; Halbesleben et al. (2010) argue that workarounds can this is best achieved with a well-planned strategy. be positive and creative; evaluating them in an unbiased Experts in HIT implementation (D. Sutton, personal fashion may inform more effi cient and safe processes. If communication, September 18, 2014) emphasize that administrators view workarounds as opportunities to ex- successful deployment includes all interested parties, in plore the limitations of the system and engage with all phases of the project. Thus, clinical end-users, lead- nurses to better understand root causes, multiple bene- ership, and administrators are all engaged in design, fi ts can result. For example, the leaders might consider testing, training, as well as ongoing monitoring and creating a quality improvement teams that collect data support. Monitoring for adoption and compliance is im- on workarounds and use prevalent workarounds as op- portant and will be most effective if it can discriminate portunities to identify and reengineer ineffi cient or risk- between true problems with compliance and techno- prone processes. logical failures or clinically supported deviations from Regardless, an institution’s leadership should con- standard use. sider viewing nursing workarounds in light of the multi- The role of high-quality training cannot be overem- ple contributory factors that underlie them. True patient phasized. It is especially important to provide detailed safety will be enhanced, nurse frustration levels will de- teaching that clearly outlines how correct use of a given crease, and nurses will be more likely to embrace future technology supports safe practice. Organizations may system and technology changes, believing that the lead- be tempted to think that “tech savvy” users will require ership is committed to instituting working solutions to minimal training; however, it is critical that they are safety and quality challenges.

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OONJ799_LRNJ799_LR 239239 110/07/150/07/15 5:085:08 PMPM ACKNOWLEDGMENT Jameton , A. ( 1984 ). Nursing practice: the ethical issues . The authors thank Darinda Sutton, MSN, RN-BC, for Englewood Cliffs, NJ: Prentice-Hall . her thoughtful review of the manuscript and input on Kälvemark , S. , Höglund , A. T. , Hansson , M. G. , Westerholm , best practices for the implementation of HIT. P. , & Arnetz , B. ( 2004 ). Living with confl icts—ethical dilemmas and moral distress in the sys- tem. Social Science & Medicine , 58 ( 6 ), 1075 – 1084. doi: R EFERENCES http://dx.doi.org/10.1016/S0277-9536(03)00279-X Clarke , J. R. , Lerner , J. C. , & Marella , W. ( 2007 ). The role Melnyk , B. M. , & Fineout-Overholt , E. (2005 ). Evidence-based for leaders of health care organizations in patient practice in nursing & healthcare: A guide to best practice . safety. American Journal of Medical Quality , 22 (5 ), Philadelphia, PA: Lippincott Williams & Wilkins. 311– 318 . doi:10.1177/1062860607304743 Musto , L. C. , Rodney , P. A. , & Vanderheide , R. ( 2015 ). Toward Classen , D. C. , Avery , A. J. , & Bates , D. W. ( 2007 ). Evaluation interventions to address moral distress: Navigating struc- and certifi cation of computerized provider order entry ture and agency. Nursing Ethics , 22 ( 1 ), 91 – 102 . systems . Journal of the American Medical Informatics Pauly , B. M. , C. Varcoe , C. & J . Storch, J. (2012 ). Framing Association , 14 ( 1 ), 48 – 55 . doi:10.1197/jamia.M2248 the issues: Moral distress in health care . HEC Forum , Debono , D. S. , Greenfi eld , D. , Travaglia , J. F. , Long , J. C. , 24 ( 1 ), 1 – 11 . Black , D. , Johnson , J. , & Braithwaite , J. (2013 ). Rack , L. L. , Dudjak , L. A. , & Wolf , G. A. (2012 ). Study of nurse Nurses’ workarounds in acute healthcare settings: A workarounds in a hospital using bar code medication ad- scoping review . BMC Health Services Research , 13 , 175 . ministration system. Journal of Nursing Care Quality , doi:10.1186/1472-6963-13-175 27 ( 3 ), 232 – 239 . doi:10.1097/NCQ.0b013e318240a854 Halbesleben , J. R. , Savage , G. T. , Wakefi eld , D. S. , & Rathert , C. , Williams , E. S. , Lawrence , E. R. , & Halbesleben , Wakefi eld , B. J. ( 2010 ). Rework and workarounds in J. R. (2012 ). Emotional exhaustion and workarounds nurse medication administration process: Implications in acute care: Cross sectional tests of a theoretical for work processes and patient safety . Health Care framework . International Journal of Nursing Studies , Management Review , 35 (2 ), 124 – 133 . doi:10.1097/ 49 ( 8 ), 969 – 977 . doi:10.1016/j.ijnurstu.2012.02.011 HMR.0b013e3181d116c2 Storch , J. L. ( 2005 ). Patient safety: Is it just another band- Health IT.gov . (2014 ). Retrieved July 5, 2014, from http:// wagon? Nursing Leadership , 18 ( 2 ), 39 – 55 . www.healthit.gov/providers-professionals/meaning- The Leapfrog Group . (2014 ). Retrieved July 5, 2014, from ful-use-defi nition-objectives http://www.leapfroggroup.org/ Hofmann , B. ( 2002 ). Is there a technological imperative in Vermeulen , L. C. , Rough , S. S. , Thielke , T. S. , Shane , R. R. , Ivey , health care? International Journal of Technology M. F. , Woodward , B. W. , & Zilz , D. A. (2007 ). Strategic Assessment in Health Care , 18 ( 03 ), 675 – 689 . approach for improving the medication-use process in Institute of Medicine . (2000 ). To err is human: Building a health systems: The high-performance pharmacy prac- safer health system . Washington, DC: The National tice framework . American Journal of Health-System Academies Press . Pharmacy , 64 ( 16 ), 1699 – 1710 . doi:10.2146/ajhp060558 Institute for Safe Medication Practice . (2014 ). Guidelines Westphal , J. , Lancaster , R. , & Park , D. (2014 ). Work-arounds for timely medication administration: Response to the observed by fourth-year nursing students. Western CMS “30-minute rule.” Acute Care ISPM Medication Journal of , 36 ( 8 ), 1002 – 1018. doi: Safety Alert , 19 ( 13 ). 10.1177/0193945913511707

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