The Hidden Cost of Workarounds

A Story from the Frontline

By Michaela Malouf

Names, locations, and identifying details have been changed to protect the privacy of those involved.

I knew I wanted to specialize in oncology after my very first shift on a medical oncology and palliative care floor in my final year of nursing school. I was deeply moved by the grace of my colleagues — some with 20 or 30 years of experience — as they comforted patients and their grieving families. I still remember sitting with an elderly patient who shared with me stories of the best and worst days of his life. Those quiet, candid conversations in the early hours of the morning taught me more about the meaning of life than any textbook ever could.

When I graduated, I was thrilled to secure my first RN position on that same unit I had grown so fond of. But on my very first night as a staff nurse, I felt a heaviness in the air that was different from the usual grief and loss I had come to expect.

I smiled at Anne, a colleague who had mentored me as a student. She was tough at times, but generous with her knowledge, always ready to step in and support others — the kind of nurse who held the team together. But that night, she didn’t return my greeting. She sat at the nurse’s station surrounded by flowers, cards, and homemade cookies. Something was off.

Puzzled, I asked another colleague, Sasha, what was going on. She hesitated, her eyes filled with tears, before finally saying, “It’s Anne’s anniversary.”

Confused, I wondered what kind of anniversary could bring such palpable sadness. Then Sasha explained: years earlier, Anne had been caring for a young man, newly diagnosed with cancer. His chemotherapy was ordered to be given over four days. But through a tragic error, it was administered over four hours. He survived the night but died in the ICU the next day.

Anne had carried that weight ever since, grieving his loss every year. And now I understood the collective despair that hung over the unit — it wasn’t just Anne’s grief. It was something her colleagues also carried with her.

Later that night, Sasha walked me through what had happened. This was long before electronic records, when chemotherapy orders were handwritten in paper charts and transcribed onto medication administration records (MARs). Each MAR had only seven days’ worth of space. When the week was up, nurses would transcribe everything onto a fresh MAR, double check it against the old one with another nurse and continue documenting from there.

On that particular day, the double check never happened. The unit was overwhelmed, short staffed, and Anne was the only nurse with chemotherapy experience. Tracking down another nurse felt impossible with so many critically ill patients needing urgent care. So, in that pressured moment, she bypassed the safety step and hung the chemotherapy herself.

I don’t need to explain the outcome. But what struck me, as a brand-new nurse, was that this could have been anyone. It could have been me.

And what also struck me was Anne’s courage. She had stayed. She chose to continue working on the same unit, alongside the same colleagues, despite carrying the memory of that tragic day. It reminded me that in nursing, one decision made under pressure can change everything — not because of bad intentions, but because of impossible circumstances.

Why Workarounds Happen

What happened that night wasn’t about carelessness. It was about impossible circumstances. Anne didn’t skip the double check because she didn’t care — she skipped it because the unit was stretched beyond capacity, and she was trying to do right by her patients. That decision was human, understandable… and devastating.

In health care, we’ve all been there. Faced with too many tasks and not enough time, we take shortcuts: skipping a double check, documenting later, clicking past an alert. These choices feel small in the moment, but they’re signals of something bigger — signals that the system isn’t working for the people inside it.

The Hidden Risks of Workarounds

The trouble with workarounds is that they don’t just solve today’s problem – they also hide tomorrows. When we “make it work” in the moment, leaders never see the broken processes, the missing staff, or the tools that don’t fit the job. Over time, these fixes create:

• Inconsistency — different staff take different shortcuts, creating variability in care.
• Safety risks — bypassing intended safeguards removes checks designed to protect patients.
• Moral distress — staff know they’re compromising standards, which erodes wellbeing.
• Masked root causes — organizations lose the chance to learn what’s really broken.

Turning Workarounds into Learning Opportunities

What if we treated workarounds not as individual failings, but as valuable clues? Every time a nurse, physician, or aide has to bend the process just to get through the day, that’s feedback about where our systems are letting people down. If we listen, these moments can point the way toward meaningful, lasting improvement.

Here are a few ways we can do that:

• Create safe spaces to share workarounds without fear of blame.
• Collect them systematically, just like near-miss reports.
• Look for patterns — are workarounds clustering in certain units, times of day, or types of tasks?
• Co-design solutions with the staff who know the problem best.
• Celebrate honesty and courage — staff who surface workarounds are not troublemakers; they’re catalysts for change.

Closing Reflection

Anne’s story will never leave me. It taught me that none of us are immune to the pressures that make workarounds feel necessary. But it also taught me that courage isn’t just about persevering after tragedy — it’s about creating a culture where we don’t have to rely on workarounds in the first place.

Every workaround is a signal. If we’re willing to listen, it can guide us toward safer, stronger, and more supportive systems for patients and staff alike.

Further Reading on Workarounds in Health Care

If this story resonates, here are a few studies and cases that explore the broader impact of workarounds:

• Tucker, A. (AHRQ). Workarounds and Resiliency on the Front Lines of Health Care. PSNet.
• Boonstra, A., et al. (2021). Persisting workarounds in Electronic Health Record System use. BMC Medical Informatics & Decision Making.
• Koppel, R., et al. (2008). Workarounds in Barcode Medication Administration Systems. J Am Med Inform Assoc.
• Halbesleben, J., et al. (2010). Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Health Care Management Review.
• Clark, A., et al. (2025). Do healthcare professionals work around safety standards, and should we be worried? A scoping review. BMJ Quality & Safety.

Michaela is a Clinical Quality Consultant with Cancer Care Alberta's Quality Safety and Practice Integration team. Michaela is passionate about improving patient safety and pulls on her experience as an Oncology nurse to bring a front-line perspective to addressing practice and patient safety concerns within Cancer Care.