Chapter 15: The Safety-II Revolution |
Learning from Workarounds and Building Resilient Healthcare Systems |
Executive Summary |
This chapter shifts the lens through which we view workarounds in healthcare technology. Traditionally, workarounds---deliberate deviations from intended processes---have been seen as problems to be eliminated. This chapter introduces the Safety-II perspective, which recognizes that workarounds are context-dependent responses to system barriers and can have mixed outcomes. Rather than punishing workarounds, healthcare organizations can learn from them to build more resilient systems. |
We begin by examining the Safety-I vs. Safety-II paradigms. Traditional Safety-I views safety as the absence of adverse events and emphasizes rule-following. Safety-II recognizes that standardized procedures cannot account for all scenarios in complex systems and that workarounds often serve legitimate purposes. This paradigm shift is essential for understanding how to improve barcode and RFID system implementation. |
We then examine comprehensive research on workarounds in barcode medication administration (BCMA). A 2025 case study in a large tertiary hospital identified 22 distinct workarounds, 43 contributing factors, 9 potential desired outcomes, and 9 potential undesired outcomes. The study emphasizes that tackling contributing factors is crucial to reducing the frequency and risks associated with workarounds. |
The chapter then presents five learning guidelines derived from the Safety-II perspective: prioritization of workarounds based on risk; emphasis on risk reduction rather than elimination; data-driven focus groups to investigate workarounds; recognition of limitations of workarounds as a source of learning; and use of language consistent with Safety-II, accompanied by a new workaround definition that acknowledges their adaptive function. |
We then integrate findings from a 2025 systematic review of barcode technology implementation, which found that workarounds were reported in 8 of 11 qualitative studies as responses to barriers. The review identified 10 common themes, with three---materials, system design, and work environment---exclusively associated with barriers. This confirms that workarounds are not random acts of non-compliance but systematic responses to predictable system failures. |
The chapter then examines Chinese case studies that demonstrate effective learning from workarounds. West China Hospital implemented RFID-enabled multi-technology integration for central transport, achieving 34.2% reduction in phone calls and significant improvements in traceability. Shenzhen Pingshan Hospital's lightweight RFID module, developed at only 6-8% of commercial system costs, reduced discrepancies to 1% and achieved 98% reduction in unrecorded transfers. Yijishan Hospital completed an RFID-based hospital logistics research project that has become a replicable model. |
The chapter concludes with a synthesis of findings and practical recommendations for healthcare organizations to adopt Safety-II principles in their AIDC implementation strategies. |
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15.1 The Traditional View: Safety-I and the Problem of Workarounds |
For decades, healthcare has operated under what safety scientists call the Safety-I paradigm. Under Safety-I, safety is defined as the absence of undesired outcomes---no medication errors, no patient falls, no surgical complications. The focus is on preventing things that go wrong. |
Within this paradigm, workarounds are seen as threats. A workaround is defined as 'a deliberate deviation from an intended work process or procedure, used to overcome an obstacle and carry out a task more efficiently and effectively' . From the Safety-I perspective, any deviation from the prescribed process is undesirable and should be eliminated. |
This perspective has dominated healthcare risk management. When a nurse bypasses barcode scanning and manually enters a medication number, the incident is logged as a 'near miss' or 'process deviation.' The nurse may be retrained or disciplined. The underlying assumption is that if everyone would just follow the rules, the system would work perfectly. |
But there is a fundamental problem with this assumption: standardized procedures cannot account for all scenarios in complex systems. A hospital is not an assembly line. Patients are unique. Equipment fails. Staff are under pressure. The gap between design assumptions and operational reality is inevitable. |
A 2025 study published in Applied Ergonomics addresses this gap directly. The authors note: 'Studies both in healthcare and in other complex domains such as aviation suggest that workarounds in digital technologies are ubiquitous and paradoxically concealed from the view of managers. A reason for this hiding is the underlying Safety-I paradigm of most organisations, aligned with the normative definition of workarounds and that regards them as undesirable and avoidable.' |
The problem is not just that workarounds are hidden---it is that organizations miss opportunities to learn. As the authors emphasize, 'learning should be the basis for any improvement.' If workarounds are treated only as violations, the systemic factors that caused them remain unaddressed. |
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15.2 The Safety-II Alternative: Learning from Workarounds |
Safety-II offers a fundamentally different perspective. Emerging from resilience engineering, Safety-II is 'concerned with understanding how safety emerges from both design and informal self-organisation, besides recognising that workarounds can serve legitimate purposes.' |
Under Safety-II, safety is not just the absence of negative outcomes---it is the presence of capacity to respond to variability. A safe system is one that can adapt when things do not go as planned. Workarounds are not necessarily threats; they are evidence of adaptive capacity. |
The Safety-II perspective recognizes several key principles: |
Procedures cannot cover all scenarios: In complex systems, standardized procedures cannot account for every situation. Healthcare workers must exercise judgment and adapt. |
Workarounds have mixed outcomes: The same workaround might prevent harm in one context and cause harm in another. Context matters. |
Punishment drives workarounds underground: When organizations punish workarounds, they do not eliminate them---they just make them invisible. Hidden workarounds cannot be studied or improved. |
Learning requires psychological safety: Staff will only disclose workarounds if they believe the workplace is safe for interpersonal risk-taking. |
A 2025 systematic review reinforces this perspective. The review found that workarounds were reported in 8 of 11 qualitative studies as 'responses to the barriers'---not random acts of non-compliance but rational adaptations to system failures . This finding is consistent with the Safety-II view that workarounds emerge from the gap between design assumptions and operational reality. |
The 2025 Applied Ergonomics study proposes a new definition of workarounds aligned with Safety-II: workarounds are 'deliberate deviations from an intended work process or procedure, used to overcome an obstacle and carry out a task more efficiently and effectively.' The key addition is recognition that workarounds can have both desired and undesired outcomes---and that understanding both is essential for learning. |
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15.3 Empirical Evidence: Workarounds in Barcode Medication Administration |
A comprehensive 2025 case study provides the most detailed empirical evidence on workarounds in barcode medication administration (BCMA). Conducted in a large tertiary public university hospital with approximately 6000 employees, 900 hospitalization beds, and 150 ICU beds, the study used multiple methods: documentary analysis, shadowing of caregivers, interviews, focus groups, a survey for assessing risks of workarounds, and a psychological safety survey. |
The 22 Workarounds Identified |
The study identified 22 distinct workarounds in the BCMA process. These included: |
Bypassing barcode scanning entirely: Administering medications without scanning, relying on manual verification instead. This workaround was typically a response to scanner malfunctions, damaged barcodes, or time pressure. |
Omitting process steps: Scanning the patient wristband but not the medication, or vice versa. This workaround often occurred when staff were interrupted or when the system required steps that seemed redundant. |
Unauthorized process steps: Manually entering medication identification numbers instead of scanning. This workaround was typically a response to barcodes that would not scan---damaged labels, poorly placed codes, or missing unit-dose barcodes. |
Sequencing workarounds: Performing scanning steps in a different order than prescribed. This workaround occurred when the prescribed order conflicted with natural workflow. |
Documentation workarounds: Signing off medications as administered before administration, or documenting administration without verification. This workaround typically occurred under extreme time pressure or when the system was slow to respond. |
The 43 Contributing Factors |
The study identified 43 contributing factors that enabled or encouraged workarounds. These fell into several categories: |
Technology-related factors: |
- Scanner malfunctions or slow response times |
- Damaged or poorly placed barcodes on wristbands or medications |
- System timeouts requiring re-authentication |
- Incompatible systems that did not communicate seamlessly |
Workflow-related factors: |
- Interruptions during medication preparation and administration |
- Time pressure from high patient loads |
- Competing priorities (responding to call lights, assisting other staff) |
- Inefficient layout of medication storage and preparation areas |
Organizational factors: |
- Insufficient staffing levels |
- Inadequate training on system features and troubleshooting |
- Lack of psychological safety for reporting workarounds |
- Performance metrics that emphasized speed over accuracy |
Environmental factors: |
- Poor lighting for barcode scanning |
- Crowded medication preparation areas |
- Distance between medication storage and patient rooms |
The Mixed Outcomes |
Critically, the study identified both desired and undesired outcomes associated with workarounds: |
Potential desired outcomes (9 identified): |
- Faster medication administration, allowing more time for patient care |
- Reduced frustration when technology failed |
- Ability to complete tasks despite system limitations |
- Prevention of delays in critical medication administration |
Potential undesired outcomes (9 identified): |
- Medication errors (wrong patient, wrong drug, wrong dose) |
- Missed documentation leading to duplicate doses |
- Inability to track medication administration for billing or recall purposes |
- Increased risk of adverse drug events |
The key insight is that the same workaround can produce desired outcomes in some contexts and undesired outcomes in others. A nurse who manually enters a medication number because the barcode is damaged may be preventing a delay in critical medication administration---a desired outcome. But that same manual entry bypasses the verification that the barcode was designed to provide---potentially allowing an error. |
Implications for Organizations |
The study's authors emphasize: 'Tackling the contributing factors is crucial to reduce the frequency and risks associated with workarounds.' This means that organizations should focus on fixing the system problems that drive workarounds, not punishing the clinicians who develop them. |
The study also highlights the role of psychological safety: 'The willingness of disclosing workarounds is also influenced by psychological safety, namely the shared belief held by team members that the workplace is safe for interpersonal risk-taking.' When staff fear punishment for disclosing workarounds, they hide them---and hidden workarounds cannot be studied or improved. |
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15.4 Five Learning Guidelines from Safety-II |
Based on their case study findings, the authors propose five learning guidelines for organizations seeking to learn from workarounds. |
Guideline 1: Prioritization of Workarounds Based on Risk |
Not all workarounds are equally dangerous. Organizations should prioritize investigation of workarounds that have the highest potential for patient harm. This requires systematic risk assessment of identified workarounds, considering both frequency and potential severity. |
In practice, this means creating a risk matrix for workarounds. A workaround that occurs daily and could cause severe harm (e.g., bypassing scanning for high-risk medications like insulin or chemotherapy) should be investigated immediately. A workaround that occurs rarely and has low harm potential might be addressed later or accepted as necessary adaptation. |
Guideline 2: Emphasis on Risk Reduction Rather Than Elimination |
The goal should not be to eliminate all workarounds---that is neither possible nor desirable. Some workarounds serve legitimate adaptive purposes, enabling care to continue when systems fail. The goal should be to reduce the risks associated with workarounds while preserving their adaptive benefits. |
This means focusing on the contributing factors that make workarounds risky. If scanners are slow, fix the scanners---do not just tell nurses to scan anyway. If barcodes are frequently damaged, improve label quality---do not just retrain staff on proper scanning technique. |
Guideline 3: Data-Driven Focus Groups |
Understanding workarounds requires direct engagement with the staff who develop them. The study recommends data-driven focus groups where workaround data is presented to staff and they are asked to explain why workarounds occur and what would help. |
These focus groups should be psychologically safe---staff must believe they can speak honestly without fear of punishment. The focus should be on understanding the system, not assigning blame. |
Guideline 4: Recognition of Limitations of Workarounds as a Source of Learning |
While workarounds are valuable sources of learning, they have limitations. Staff may not be aware of all workarounds, or may not remember them accurately. Some workarounds are so routine that staff no longer perceive them as deviations. |
Organizations should complement workaround investigation with other methods: direct observation, process mapping, analysis of near-miss reports, and review of system logs. Multiple methods provide a more complete picture. |
Guideline 5: Use of Language Consistent with Safety-II |
Language matters. Referring to workarounds as 'violations' or 'deviations' reinforces the Safety-I paradigm and discourages disclosure. The study proposes a new definition that acknowledges the adaptive function of workarounds, accompanied by neutral or positive framing. |
In practice, this means changing how workarounds are discussed. Instead of 'nurse bypassed safety check,' say 'nurse adapted to system failure.' Instead of 'non-compliance with protocol,' say 'workaround enabled task completion despite technical barrier.' The goal is not to excuse unsafe behavior but to create conditions where honest discussion of workarounds is possible. |
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15.5 The Systematic Review Evidence |
The 2025 systematic review of barcode technology implementation provides complementary evidence that reinforces the Safety-II perspective . The review analyzed 11 qualitative studies from 6 countries and identified 10 common themes. |
Workarounds as Responses to Barriers |
The review found that 'workarounds, such as bypassing barcoding, omitting process steps, and unauthorized process steps, were reported in 8 studies as responses to the barriers.' This finding is crucial: workarounds are not random or arbitrary. They are systematic responses to identifiable barriers. |
The barriers that drove workarounds fell into three categories exclusively associated with barriers (no facilitator counterparts): |
Materials barriers: |
- No unit-dose barcodes on medications |
- Damaged barcodes on wristbands or medication packaging |
- Multiple barcodes on same package (confusing which to scan) |
- Patient wristbands damaged by fluids, chewing, or wear |
- Non-formulary medications without readable barcodes |
System design barriers: |
- Need to use partial doses or different formulations than what the barcode expects |
- Difficulties altering automatic documentation based on scanned dose |
Work environment barriers: |
- Insufficient staff to support the system |
- Rushed conditions that prevent proper scanning |
- Competing priorities pulling attention away from scanning |
The Human Factor Cannot Be Designed Away |
The review's findings demonstrate that no matter how well-designed a technology, it will be used by humans working under real-world constraints. Damaged barcodes will occur. Scanners will malfunction. Staff will be rushed. These are not anomalies---they are predictable features of healthcare delivery. |
The implication is not that technology is useless, but that implementation must account for these realities. Systems should be designed to be resilient---to function acceptably even when things go wrong. This means redundant verification, user-friendly error recovery, and clear procedures for handling exceptions. |
Implications for Organizations |
The review's authors conclude: 'This review underscores the complexity of implementing and maintaining high-leverage, technology-based systemic defenses in clinical practice. The findings provide a foundation for the improvement of the safety and usability of barcode technologies in hospital settings.' |
For organizations implementing AIDC technologies, this means: |
Plan for failure: Assume that barcodes will be damaged, scanners will malfunction, and staff will be interrupted. Design systems that can handle these failures gracefully. |
Invest in materials quality: The 'materials' barrier is exclusively associated with barriers---meaning no study identified it as a facilitator. This is a system problem that requires investment in better wristbands, labels, and packaging. |
Address work environment factors: Insufficient staffing and rushed conditions are not excuses---they are realities. Systems must be designed to work under these conditions, not idealized conditions. |
Create psychological safety: Staff will only disclose workarounds if they believe it is safe to do so. Organizations must actively create cultures where reporting workarounds is encouraged and rewarded. |
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15.6 Learning from Workarounds: A Practical Framework |
Based on the Safety-II literature and systematic review evidence, a practical framework for learning from workarounds emerges. |
Step 1: Identify Workarounds |
Workarounds can be identified through multiple methods: |
- Direct observation of clinical workflows |
- Analysis of system logs (e.g., scans that were bypassed, manual entries) |
- Staff interviews and focus groups |
- Review of near-miss and incident reports |
The key is to use multiple methods, as no single method captures all workarounds. Observation may miss workarounds that occur when observers are not present. Staff reports may miss workarounds that have become routine. System logs may miss workarounds that involve manual processes. |
Step 2: Analyze Contributing Factors |
For each identified workaround, investigate the contributing factors. The 43 factors identified in the BCMA case study provide a useful starting framework. Ask: |
- What technology factors contributed(Scanners, barcodes, system speed, interface design) |
- What workflow factors contributed(Interruptions, time pressure, task sequencing) |
- What organizational factors contributed(Staffing, training, metrics, culture) |
- What environmental factors contributed(Lighting, layout, noise, crowding) |
The goal is to understand the system, not to assign blame. Focus on factors that can be changed, not on individual behavior. |
Step 3: Assess Risk |
Not all workarounds require immediate intervention. Assess each workaround on two dimensions: |
Frequency: How often does this workaround occur(Daily, weekly, monthly, rarely) |
Potential severity: If the workaround leads to an error, how severe could the harm be(Minor, moderate, severe, catastrophic) |
Workarounds that are both frequent and high-severity should be prioritized for intervention. Workarounds that are rare and low-severity might be accepted as necessary adaptation. |
Step 4: Design Interventions |
Interventions should address the contributing factors identified in Step 2, not just the workaround itself. If the workaround is caused by damaged barcodes, fix the barcode quality---do not just retrain staff on scanning. |
Possible interventions include: |
Technology improvements: Better scanners, more durable wristbands, redesigned labels |
Workflow redesign: Changing the sequence of tasks, adding verification steps, reducing interruptions |
Organizational changes: Adjusting staffing levels, revising performance metrics, creating psychological safety |
Environmental changes: Improved lighting, redesigned workspaces, reduced crowding |
Step 5: Evaluate and Iterate |
After implementing interventions, evaluate their effectiveness. Have the targeted workarounds decreased in frequencyHave new workarounds emergedHave unintended consequences occurred |
The evaluation should include both quantitative measures (scan compliance rates, error rates) and qualitative feedback from staff. Continuous improvement requires continuous learning. |
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15.7 Chinese Case Studies: Learning from Implementation |
Several Chinese case studies demonstrate successful learning from implementation challenges, embodying the Safety-II principle of adaptive capacity. |
West China Hospital: Multi-Technology Integration for Central Transport |
West China Hospital, one of China's largest and most prestigious medical centers, implemented an intelligent dispatch system integrating multiple technologies including RFID, artificial intelligence, and mobile applications . The system addressed a common challenge: coordinating patient transport, specimen delivery, and medication distribution across a large, complex hospital. |
The Challenge: Before implementation, central transport coordination relied heavily on phone calls. Staff spent significant time calling to request transport, confirm arrivals, and track status. Delays were common, and traceability was limited. The 2018 national electronic medical record rating standards required tracking of patient transfers, examinations, medications, and other transport activities. |
The Solution: The hospital developed an intelligent dispatch system integrating HIS (Hospital Information System), laboratory information systems, medical technology appointment platforms, and call systems. Key technologies included: |
RFID for real-time tracking: Transporters and items were tagged with RFID, enabling real-time location tracking and status monitoring. |
Mobile applications: Transporters accessed the system via mobile devices to view, accept, and complete tasks. |
AI for scheduling: The system automatically generated multi-dimensional statistical reports and optimized resource allocation. |
The Results: |
- Monthly specimen volume: approximately 650,000 tubes |
- Monthly medical document transport: approximately 100,000 items |
- June 2024 medication orders: over 1.2 million |
- Pharmacy PDA scan rate: 96.09% |
- Transport PDA scan rate: 93.81% |
- Ward receiving PDA scan rate: 96.14% |
- Phone calls reduced by approximately 34.2% (from 1,000 to 658 daily average) |
- Patient satisfaction improved from 95% to 98% |
The Learning: West China Hospital's success demonstrates the value of multi-technology integration and systematic implementation. Rather than trying to eliminate all variability, the system was designed to provide visibility and traceability while adapting to real-world conditions. The high scan rates (all above 93%) indicate that staff accepted and used the technology---likely because it reduced phone calls and improved efficiency, providing clear value. |
Shenzhen Pingshan Hospital: Lightweight RFID Innovation |
As documented in previous chapters, Shenzhen Pingshan Maternal and Child Health Hospital developed a lightweight RFID inventory module at only 6-8% of commercial system costs . This case is particularly instructive for the Safety-II perspective. |
The Challenge: The hospital faced inefficient fixed asset inventory, discrepancies between records and physical assets, and high management costs. Commercial RFID systems were too expensive for the hospital's budget. |
The Solution: The hospital developed a lightweight RFID module with: |
- UHF electronic tags and general-purpose handheld PDAs |
- Focused functionality on core fixed asset management |
- Modular architecture for rapid iteration (new features: 2.5 hours average; hardware adaptation: 1.2 hours) |
- Quarterly cycle inventory for dynamic asset monitoring |
The Results: |
- Discrepancy rate reduced to 1% |
- Unrecorded transfers reduced by 98% |
- Over 90% of misplaced equipment returned within one week |
- Equipment utilization improved by 8% |
- Financial reconciliation time: from 2 weeks to 2 days (80% reduction) |
- Asset transfer registration: from 15 minutes to 3 minutes (70 staff hours saved annually) |
The Learning: The Pingshan case demonstrates that expensive commercial systems are not always necessary. By focusing on core functionality, using off-the-shelf hardware, and designing for rapid iteration, even a resource-constrained hospital can achieve substantial improvements. This is Safety-II in action: adaptive capacity to work within constraints while still achieving safety and efficiency goals. |
Yijishan Hospital: RFID Hospital Logistics Research |
Yijishan Hospital, affiliated with Wannan Medical College, completed a research project on RFID-based hospital logistics refined management . The project, which passed review by the National Health Commission Hospital Management Institute, systematically constructed an integrated RFID application solution for medical waste collection, storage, and transport. |
The Results: The project has become a replicable model ('Yijishan Model') for public hospital logistics management reform in Anhui Province. |
The Learning: The Yijishan case demonstrates the value of systematic research and documentation. By rigorously evaluating their implementation and publishing the results, the hospital created a model that other organizations can adopt. This is learning at the institutional level---not just improving one hospital but contributing to the broader evidence base. |
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15.8 The Role of Psychological Safety |
A theme that emerges repeatedly in the workaround literature is psychological safety. The 2025 Applied Ergonomics study explicitly measured psychological safety as part of their investigation. The authors note: 'The willingness of disclosing workarounds is also influenced by psychological safety, namely the shared belief held by team members that the workplace is safe for interpersonal risk-taking.' |
Organizations with high psychological safety have several characteristics: |
Leaders model vulnerability: When leaders admit mistakes and acknowledge uncertainty, they signal that it is safe to do so. When leaders punish errors, they signal that risks should be hidden. |
No-blame policies are enforced: Policies that promise no punishment for error reporting are only effective if they are consistently enforced. Staff quickly learn whether 'no blame' is real or rhetorical. |
Workarounds are investigated, not punished: When a workaround is identified, the response is 'why did this happen' not 'who did this' The focus is on system improvement, not individual discipline. |
Feedback loops are closed: When staff report workarounds or near misses, they receive feedback on what was learned and what changed. This reinforces that reporting is valued. |
The systematic review's finding that workarounds were reported in 8 of 11 studies suggests that workarounds are nearly universal. The question is not whether they occur, but whether organizations know about them. Psychological safety determines the answer. |
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15.9 From Safety-I to Safety-II: Practical Steps |
Transitioning from Safety-I to Safety-II is not a one-time event but an ongoing organizational shift. Practical steps include: |
Step 1: Audit Current Safety Language |
Review incident reports, safety committee minutes, and performance reviews. Count how often language assigns blame to individuals versus identifying system factors. If the language is predominantly individual-focused, the organization is operating under Safety-I. |
Step 2: Revise Incident Reporting Systems |
Modify incident reporting forms to include questions about contributing factors, not just what happened. Ask: 'What made it difficult to follow the correct process' 'What system factors contributed' 'What would have made it easier to do the right thing' |
Step 3: Create Workaround Review Processes |
Establish regular forums where workarounds can be discussed without fear of punishment. These should be multidisciplinary, including frontline staff, managers, and technology experts. The goal is learning, not discipline. |
Step 4: Measure Psychological Safety |
Use validated psychological safety surveys to assess whether staff believe it is safe to report errors and workarounds. Track changes over time and correlate with incident reporting rates. |
Step 5: Close the Feedback Loop |
When workarounds lead to system improvements, communicate those improvements back to staff. Show them that their reports led to change. This reinforces the value of reporting and builds psychological safety. |
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15.10 Implications for AIDC Implementation |
The Safety-II perspective has direct implications for how healthcare organizations implement barcode and RFID technologies. |
Implication 1: Plan for Workarounds |
Assume that workarounds will occur. Design systems with this assumption in mind. Include: |
- Redundant verification for critical processes |
- Clear procedures for handling exceptions (damaged barcodes, scanner failures) |
- User-friendly error recovery (easy ways to correct mistakes) |
Implication 2: Monitor for Workarounds |
Actively monitor for workarounds using multiple methods: |
- System logs (scan rates, manual entries, timing patterns) |
- Direct observation |
- Staff interviews and focus groups |
- Analysis of near-miss reports |
Implication 3: Investigate Contributing Factors |
When workarounds are identified, investigate the contributing factors. The 43 factors identified in the BCMA study provide a useful framework. Focus on: |
- Materials (barcode quality, wristband durability) |
- System design (workflow integration, alert configuration) |
- Work environment (staffing, time pressure, interruptions) |
Implication 4: Fix Systems, Not People |
When contributing factors are identified, fix them. Do not retrain or discipline staff for workarounds that were caused by system failures. Fix the damaged printer. Improve the wristband quality. Add staff during peak hours. |
Implication 5: Create Psychological Safety |
Actively create conditions where staff feel safe disclosing workarounds. This requires: |
- Leadership commitment to no-blame investigation |
- Consistent enforcement of no-blame policies |
- Feedback loops that show reporting leads to improvement |
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15.11 Detailed Summary |
This chapter has introduced the Safety-II perspective as a framework for understanding and learning from workarounds in healthcare AIDC implementation. Drawing on a 2025 case study of BCMA workarounds, a 2025 systematic review of barcode technology implementation, and Chinese case studies from West China Hospital, Shenzhen Pingshan Hospital, and Yijishan Hospital, we have examined how organizations can move from punishing workarounds to learning from them. |
Key Findings |
1. Workarounds are universal and systematic. Workarounds were reported in 8 of 11 qualitative studies as responses to barriers. They are not random acts of non-compliance but rational adaptations to system failures . |
2. The Safety-I paradigm dominates but is limited. Traditional Safety-I views workarounds as threats to be eliminated. However, standardized procedures cannot account for all scenarios in complex healthcare systems . |
3. Safety-II offers an alternative. Safety-II recognizes that workarounds can serve legitimate adaptive purposes and that learning from them is essential for building resilient systems . |
4. A 2025 case study identified 22 workarounds, 43 contributing factors, and mixed outcomes in BCMA. Tackling contributing factors is crucial to reducing the frequency and risks associated with workarounds . |
5. Five learning guidelines emerge from Safety-II: prioritization based on risk, emphasis on risk reduction rather than elimination, data-driven focus groups, recognition of limitations, and use of language consistent with Safety-II . |
6. Three themes---materials, system design, and work environment---are exclusively associated with barriers. These are system problems requiring system solutions, not individual behavior change . |
7. Psychological safety is essential for learning from workarounds. Staff will only disclose workarounds if they believe the workplace is safe for interpersonal risk-taking . |
8. Chinese case studies demonstrate effective adaptation. West China Hospital achieved 34.2% reduction in phone calls through RFID-enabled multi-technology integration. Shenzhen Pingshan Hospital achieved 1% discrepancy rate at 6-8% of commercial system costs. Yijishan Hospital developed a replicable 'Yijishan Model' for RFID-based hospital logistics . |
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Implications for Practice |
For healthcare administrators and technology planners, several principles emerge: |
Shift from Safety-I to Safety-II. Treat workarounds as learning opportunities, not violations. Investigate contributing factors, not individual behavior. |
Create psychological safety. Staff will only disclose workarounds if they believe it is safe. Leadership commitment, no-blame policies, and closed feedback loops are essential. |
Plan for workarounds. Assume they will occur. Design systems with redundant verification, clear exception procedures, and user-friendly error recovery. |
Monitor actively. Use multiple methods---system logs, observation, interviews, focus groups---to identify workarounds. Do not rely solely on incident reports. |
Fix systems, not people. When workarounds are identified, investigate contributing factors and fix them. Do not retrain or discipline staff for system failures. |
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The Core Insight |
The Safety-II revolution is not about accepting unsafe behavior. It is about recognizing that workarounds are inevitable in complex systems and that learning from them is essential for improvement. When a nurse bypasses barcode scanning, the question should not be 'Who did this' but 'Why was this necessary' The answer will reveal a system problem---damaged barcode, slow scanner, inadequate staffing---that can and should be fixed. |
The organizations that succeed in implementing barcode and RFID technologies are not those that eliminate all workarounds---an impossible goal. They are those that create conditions where workarounds are visible, understood, and addressed. They treat workarounds as diagnostic data, not evidence of failure. They fix systems, not people. |
This is the path to resilient healthcare. Not through perfect compliance with perfect procedures, but through adaptive capacity to respond when things do not go as planned. Barcodes and RFID are tools. Safety-II is the mindset that determines whether those tools achieve their potential. |
cs@easiersoft.com