title: Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.
abstract: BACKGROUND
  Concerns with the usability of electronic prescribing (ePrescribing) systems can lead to the development of workarounds by users.
  
  
  OBJECTIVE
  To investigate the types of workarounds users employed, the underlying reasons offered and implications for care provision and patient safety.
  
  
  METHODS
  We collected a large qualitative data set, comprising interviews, observations and project documents, as part of an evaluation of ePrescribing systems in five English hospitals, which we conceptualised as case studies. Data were collected at up to three different time points throughout implementation and adoption. Thematic analysis involving deductive and inductive approaches was facilitated by NVivo 10.
  
  
  RESULTS
  Our data set consisted of 173 interviews, 24 rounds of observation and 17 documents. Participating hospitals were at various stages of implementing a range of systems with differing functionalities. We identified two types of workarounds: informal and formal. The former were informal practices employed by users not approved by management, which were introduced because of perceived changes to professional roles, issues with system usability and performance and challenges relating to the inaccessibility of hardware. The latter were formalised practices that were promoted by management and occurred when systems posed threats to patient safety and organisational functioning. Both types of workarounds involved using paper and other software systems as intermediaries, which often created new risks relating to a lack of efficient transfer of real-time information between different users.
  
  
  CONCLUSIONS
  Assessing formal and informal workarounds employed by users should be part of routine organisational implementation strategies of major health information technology initiatives. Workarounds can create new risks and present new opportunities for improvement in system design and integration.
authors.affiliation: Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh EH8 9DX, UK.
authors.forename: Kathrin M
authors.initials: KM
authors.lastname: Cresswell
authors.affiliation: Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh EH8 9DX, UK.
authors.forename: Hajar
authors.initials: H
authors.lastname: Mozaffar
authors.affiliation: Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh EH8 9DX, UK.
authors.forename: Lisa
authors.initials: L
authors.lastname: Lee
authors.affiliation: Institute for the Study of Science, Technology and Innovation, The University of Edinburgh, EH1 1LZ, Edinburgh, UK.
authors.forename: Robin
authors.initials: R
authors.lastname: Williams
authors.affiliation: Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh EH8 9DX, UK.
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
mesh_terms: D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D055695:Electronic Prescribing; D004739:England; D006282:Health Personnel / Q000523:psychology*; D006761:Hospitals; D006801:Humans; D007407:Interviews as Topic; D019982:Organizational Case Studies; D061214:Patient Safety; D024382:Professional Role; D014584:User-Computer Interface; D057188:Workflow; D016526:Workload
keywords: Decision support, computerized; Health services research; Implementation science; Information technology; Qualitative research