From the perspective of frontline personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and actions are referred to as workarounds. Although workarounds "fix the problem," the system remains unaltered and thus continues to present potential safety hazards for future patients.
From a definitional point of view, it does not matter if frontline users are justified in working around a given policy or equipment design feature. What does matter is that the motivation for a workaround lies in getting work done, not laziness or whim. Thus, the appropriate response by managers to the existence of a workaround should not consist of reflexively reminding staff about the policy and restating the importance of following it. Rather, workarounds should trigger assessment of workflow and the various competing demands for the time of frontline personnel. In busy clinical areas where efficiency is paramount, managers can expect workarounds to arise whenever policies create added tasks for frontline personnel, especially when the extra work is out of proportion to the perceived importance of the safety goal.
See Primer. Few medical errors are as terrifying as those that involve patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure intended for another patient. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events.