Health IT Design That Keeps End-Users in Mind

Koppel and his colleagues identified 15 reasons why clinicians needed to use a work-around, accounting for 4.2% of patients. These reasons ranged from technology-related (not having enough scanners necessary to read barcodes and computer connected to scanner not able to fit into patients' rooms) to task-related (clinician threw away packaging accidentally, which prohibited scan), to organizational (patient missing legible wrist band and medication missing a legible bar code) among others.

"All of the work-arounds—and all of them are justified given the problems with the software—all of those are work-arounds that severely deteriorate the patient safety protections," says Koppel.

By examining where these work-arounds occurred, four of the hospitals included in the study were able to dramatically reduce the amount of overrides by analyzing why clinicians were using the work-arounds and deciding on system repairs.

"For instance, if a doctor ordered 20 mg of a pill, and the pharmacy sends up two 10 mg tablets," says Koppel. "The nurse scans the first 10 mg tablet and the bar code says, 'That's no good; I'm looking for a 20,' and the nurse is screaming, 'But 10 and 10 equals 20.'"

The facility could write a software patch that tells the scanner that the two pills equal the total amount prescribed, he says.