Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports

Hannah I. Roberts, Madaline Kinlay, Deborah Debono, Rosemary Burke, Aaron Jones, Melissa T. Baysari

Research output: Chapter in Book/Report/Conference proceedingConference proceeding contributionpeer-review

2 Citations (Scopus)
5 Downloads (Pure)


Electronic medication management systems (EMMS) have been implemented in most acute care settings in Australia to reduce medication error rates. One of the key challenges related to the introduction of EMMS in hospitals is the uptake of informal "workarounds" by clinicians, including nurses. In this study, we aimed to examine one workaround in depth, nurses not documenting medication administration in the EMMS at the time of administration. We conducted a review of incident reports to identify the factors that contribute to this workaround occurring and the consequences or potential consequences of this workaround on patients. We identified a range of contributing factors, with factors relating to the user (e.g. nurses being time poor) occurring most frequently in incident reports. The most frequently seen consequence of this workaround was the patient receiving an additional dose. This research revealed that strategies to reduce the uptake of this workaround should consider user and organisational factors rather than just EMMS design alone.

Original languageEnglish
Title of host publicationContext Sensitive Health Informatics and the Pandemic Boost
Subtitle of host publicationAll Systems Go!
EditorsAdeola Bamgboje-Ayodele, Mirela Prgomet, Craig E. Kuziemsky, Peter Elkin, Christian Nøhr
Place of PublicationAmsterdam
PublisherIOS Press
Number of pages5
ISBN (Electronic)9781643683997
ISBN (Print)9781643683980
Publication statusPublished - 22 Jun 2023
Externally publishedYes
EventContext Sensitive Health Informatics Conference - The University of Sydney, Sydney, Australia
Duration: 5 Jul 20236 Jul 2023

Publication series

NameStudies in Health Technology and Informatics
PublisherIOS Press
ISSN (Print)0926-9630
ISSN (Electronic)1879-8365


ConferenceContext Sensitive Health Informatics Conference
Abbreviated titleCSHI 2023
Internet address

Bibliographical note

Copyright the Author(s) and IOS Press 2023. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.


  • electronic medication management systems
  • incident reports
  • nurse
  • workaround


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