Hazardous Habits

How shortcuts and workarounds become the dangerous new normal

A nurse in scrubs is sitting on the hospital floor with her arms on her knees and her head in her hands.

I was standing at the med cart, measuring an insulin injection, when I saw the nurse supervisor heading my way. I froze. The top drawer of the med cart was open. A quick glance would be all she needed to see that I had pre-poured several meds to administer later in my shift.

She approached and stood next to me. “Do you have any extra hearing aid batteries?” she asked.

I held the syringe in the insulin vial with my left hand and hastily handed her a battery with my right. I watched her gaze travel down to the little paper dispensing cups full of meds and the names I’d written on tiny pieces of paper. She then looked up at me.

We locked eyes — only for a second — and then she thanked me and walked away.

What We Both Knew

In that moment of eye contact, no words were spoken, but we both knew:In that moment of eye contact, no words were spoken, but we both knew:

  • What I was doing was wrong.
  • I would not have time to administer all  medications according to protocol during my shift.
  • She did the same thing when passing meds on  this unit.
  • We would never talk about it.

The above is a true story, a memory I have of several years ago when I was working as a per diem RN in a long-term care facility that was chronically understaffed, with a pervasive culture of blame. I started that job with the knowledge and skills necessary for safe medication administration, which every nurse learns in school, and I had every every intention of following those safe procedures.

As I went through orientation, I began to notice that while my fellow nurses could demonstrate the correct protocol, many had shortcuts they followed when busy — and they were always busy. They didn’t talk about those shortcuts.

As I graduated to a charge nurse role and managing my own med cart and unit, I still attempted to follow protocols. Sometimes, I’d start out a shift doing everything by the book. Then, someone would fall, or we’d get a new admission or a nurse would go home sick. That meant I’d be extremely late with some meds while accruing lots of overtime, which was frowned upon. Soon, I was getting messages that I needed to work smarter to get out on time. I was told that if I needed help, I should contact the supervisor.

Of course, the supervisor was typically just as busy as I was and not really available to help. I felt trapped between a rock and a hard place.

Over time, it became clear that staffing throughout the facility was so lean that you could pretty much bank on someone calling out or leaving early due to sickness or some sort of emergency. This meant constantly pulling staff from one unit to help cover another. I can’t even remember a shift there that felt like a reasonable workload.

RN Career Events

I tried to adjust to these expectations and be a good employee, team player and patient advocate. More than once, I even expressed concerns about staffing to the director of nursing, but my worries seemed to fall on deaf ears.

15 Workarounds and 31 Causes

Ironically, during this same time in my career, I was also researching shortcuts and workarounds in medication administration for my second book, Successful Nurse Communication, published in 2015. At the time, medication scanning was just becoming popular in hospitals, but patient safety issues persisted — as they still do.

Between 2003 and 2006, during the early days of barcoded medication administration (BCMA), health IT expert Ross Koppel, Ph.D., FACMI, and his colleagues observed and shadowed nurses using BCMA systems at five hospitals. Their study, published in The Journal of the American Medical Informatics Association in 2008, identified 15 different types of BCMA workarounds, ranging from affixing patient identification barcodes to door jambs, computer carts, or nurses’ belt rings to carrying several patients’ pre-scanned medications on carts.

The authors identified 31 probable causes for such workarounds. Some were mechanical, including equipment-related problems (such as dead batteries, connectivity issues or scanner failure); unreadable or missing barcodes or patient identification bands; or specific medications not being correctly catalogued.

Others included the kinds of problems I had experienced, such as nurses being too busy or too distracted to follow the proper protocols, which didn’t always fit the nurses’ normal workflow. It seems we are pretty creative about bending the rules to get things done.

Lessons from the Challenger Disaster

It is one thing to cut corners on rare occasions, particularly if it’s due to emergency or equipment failure. In those situations, we might not have any real alternative. However, when we cut corners repeatedly, those shortcuts become bad habits.

As I related in the opening story, I made it a habit to pre-pour meds whenever we were short-staffed or if something else caused me to fall behind. I rationalized that it was the only way to get people their medications on schedule, or at least close to it.

I don’t think many nurses could honestly claim they’ve never once bent the rules. In many cases, nothing really comes of it. The problem is that bad habits like these lead to what Columbia University sociologist Diane Vaughan, Ph.D., has dubbed “the normalization of deviance.”

She coined this term in her analysis of the explosion that destroyed the space shuttle Challenger in 1986.

Normalization of deviance describes the natural human tendency to do something the wrong way under pressure and then make a habit of it because it hasn’t yet resulted in any significant consequences. After a while, that bad habit becomes the new normal. Instead of correcting it, we start adding more bad habits on top of the original one, setting aside yet more proper protocols and safety precautions. Eventually, something bad does happen.

Nursing Education

Talking about the Challenger disaster in a recent YouTube video, former astronaut Mike Mullane explained that because of the normalization of deviance, that devastating tragedy “was not an accident. It was a predictable surprise.”

The Fatal Cost of Distraction

How many medication errors are also predictable surprises? I don’t know of any way to know for sure, but every time I hear about a new incident, I wonder. A sobering recent example was the February 2019 indictment of Tennessee RN RaDonda Vaught, a former nurse at Vanderbilt University Medical Center in Nashville. She was charged with reckless homicide and abuse of an impaired adult in the fatal medication error that killed patient Charlene Murphey in December 2017.

Vaught admitted that she was distracted talking with a colleague when she overrode the automated medication dispensing system and administered the powerful surgical anesthetic vecuronium rather than the prescribed Versed, an anti-anxiety medication. The 75-year-old Murphey died hours later. The exact circumstances will probably be argued at length in court — Vaught has pleaded not guilty to the charges — but incidents like this are a reminder that taking even occasional shortcuts with medication administration can be deadly.

Ask Yourself Honestly

If you ever find yourself tempted to bend a rule while under pressure at work, you’re probably not the only one. Unfortunately, because we don’t usually talk about it unless someone gets in trouble (and sometimes not even then), we may have no idea just how many shortcuts the other nurses around us may be taking every day.

We need to have open and honest conversations with each other and our leaders before we develop bad habits that put our patients at risk — and before something goes terribly wrong. It’s time to break the code of silence that paralyzed me and my supervisor that day years ago.

How many of these common shortcuts have you taken?
  • Relying on memory from earlier in the day or a previous shift rather than going through the proper steps again.
  • Stopping in the middle of the process to answer an alarm and then picking up where you think you left off rather than starting over.
  • Trusting that the pharmacy sent the right dose/medication without double-checking.
  • Administering medication at what you know is the wrong time and writing it off as “close enough” or your only opportunity.
  • Using “patient refused” or “patient sleeping” as an excuse for not following protocol.
  • Overriding the automated dispensing system rather than taking steps to correct a problem such as an unreadable barcode.

Often, these bad habits reflect problems beyond the individual nurse’s ability to solve. Workflows might need to be adapted to better fit with current equipment. Buggy barcode scanners need to be replaced. The hospital might need to take steps to reduce distracting noise, minimize alarm fatigue or, most importantly, hire more staff so nurses have time to do their jobs properly.

None of those things is likely to happen if we don’t speak up. As nurses, we’re expected to be patient advocates, but to do that, we must also advocate for ourselves and ensure that our colleagues and leaders respect our concerns and our limitations.

BETH BOYNTON, RN, M.S., is an organizational development consultant specializing in communication, collaboration and culture, and the author of Medical Improv: A New Way to Improve Communication. She is currently working on an ebook series. Contact her at .

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