Patient Safety Tip of the Week

February 13, 2018    Interruptions in the ED

 

 

Our March 8, 2011 Patient Safety Tip of the Week “Yes, Physicians Get Interrupted Too!” included reference to several studies addressing the impact of interruptions and distractions on emergency physicians. Those showed that ED physicians are interrupted more often than primary care physicians (Chisholm 2001) and that interruptions occur more often during certain activities than others (Jeanmonod 2010).

 

Chisholm and colleagues (Chisholm 2011) found that emergency physicians in academic sites experienced a median of 12 interruptions per 2-hour observation period and those at community sites a median of 6 interruptions per period. Of the interruptions, almost half resulted in breaks in task. These are interruptions that result in changing tasks. The authors note that both the times spent in direct and indirect patient care and the frequency of interruptions have changed little since they did similar surveys a decade ago (Chisholm 2000). That previous work had also shown that both the number of interruptions and breaks in task increased with the average number of patients being managed simultaneously.

 

Another study of emergency physicians (Friedman 2005) showed emergency physicians at Toronto General Hospital were interrupted every 13.8 minutes on average (4.4 interruptions per hour) and that the rate of interruptions increased with increasing shift intensity. Half the interruptions were from nurses and a third from other physicians. While most interruptions did not require the physician to move to a new location, about 10% did require a move.

 

In an Australian study (Westbrook 2010) emergency department physicians were interrupted 6.6 times/h. 11% of all tasks were interrupted, 3.3% more than once. Doctors multitasked for 12.8% of time. The mean TOT (time on task) was 1:26 min. Interruptions were associated with a significant increase in TOT. However, when length-biased sampling was accounted for, interrupted tasks were unexpectedly completed in a shorter time than uninterrupted tasks. Doctors failed to return to 18.5% of interrupted tasks.

 

Another study (Jeanmonod 2010) showed that emergency physicians are interrupted more often in certain activities than others. For example, they were interrupted during charting or reviewing data about 50% of the time. Bedside interruptions were less common (26%) but had a negative impact on patient satisfaction. The majority of interruptions were initiated by another physician or nurse. Unlike the above studies, these authors found physicians rarely changed tasks after an interruption.

 

Breaks in task are especially important because one may never return appropriately to the previous task. Even when using checklists (whether in healthcare or aviation or other industry) breaks in task may result in steps of a sequence being skipped or overlooked. That is one of the reasons that during critical activities pilots use the “sterile cockpit” concept and nurses or pharmacists use a similar concept wherein they flag themselves in some manner to prevent interruptions.

 

In the Westbrook study, 11% of tasks were interrupted (and 3.5% were interrupted more than once). The total time for tasks increased with interruptions. But, interestingly, when the authors corrected for a length of time of observation bias, they found that interrupted tasks were actually completed in shorter times! They speculated that physicians may be “catching up for lost time”. We would anticipate that such shortened duration tasks, rather than being examples of improved efficiency, might actually be especially prone to errors and omissions.

 

Another new study from Johanna Westbrook and colleagues in Australia looked at the impact of several factors on performance of emergency department physicians (Westbrook 2018). The researchers shadowed 36 emergency physicians over 120 hours. All tasks, interruptions and instances of multitasking were recorded. The task assessed for errors was physician prescribing (assessed by a pharmacist, unaware of physician status, reviewing all medication orders entered by physicians during the study period).

 

Medication orders were assessed for legal/procedural errors (eg, unapproved abbreviations, missing drug units) and clinical errors (eg, wrong drug due to a drug–disease interaction). Physicians’ working memory capacity (WMC) was measured via the OSPAN test. “Polychronicity” (ie, preference for multitasking and a belief that this is efficient) was assessed using the adapted version of the Inventory of Polychronic Values (IPVs).

 

They found that physicians experienced 7.9 interruptions/hour on average but while prescribing clinicians experienced 9.4 interruptions/hour. Those rates are comparable to those demonstrated in previous studies of ED physicians.

 

It’s no surprise: error rates increased almost three-fold when physicians were interrupted while prescribing (RR 2.82). But multitasking was also clearly related to more frequent errors (RR 1.86).

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As you’d expect, lack of sleep was associated with more frequent prescribing errors. But the magnitude of the increase was eye-opening. Having below-average sleep in the previous 24 hours was associated with a >15-fold increase in clinical error rate (RR 16.44). Our focus today is on the impact of interruptions rather than fatigue but we’ve listed our numerous columns on fatigue in healthcare at the end of today’s column.

 

Error rates also increased with each year of patient age (RR 1.05) and physician age (RR 1.07). The implication is that increasing age is associated with decreasing working memory capacity (WMC), as other studies have shown WMC to decrease with increasing age. Other studies have also shown that individuals with lower WMC scores may exhibit increased task times and more errors when interrupted. Physicians’ working memory capacity (WMC) in this study was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed.

 

But clinical error rates were inversely related to doctor seniority with residents having the highest error rate relative to consultants. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.

 

Multitasking merits specific comment. We often pride ourselves in our ability to multitask. But you’ve often heard us say that such pride is probably misplaced. Indeed, in the Westbrook study multitasking was related to an almost 2-fold increase in errors (RR 1.86). Interestingly, though, multitasking was significantly associated with legal/procedural errors (eg, unapproved abbreviations, missing drug units), but not clinical errors (eg, wrong drug due to a drug–disease interaction).

 

The Westbrook study demonstrated that the medication prescribing process is particularly prone to errors when interruptions occur and drew the analogy to nursing, where the medication administration process is also prone to errors when interruptions occur.

 

Keep in mind that not all interruptions are detrimental and many are necessary. Particularly in an ED settting, where physicians are caring for multiple patients at a time, an interruption may be critical to alert a physician to an urgent need for one of those patients. We’ve also stated before that, in such healthcare settings, focusing on just one outcome parameter (such as prescribing errors) may not accurately reflect the “big picture”. For example, if physicians were to focus on prescribing to the detriment of maintaining situational awareness for all their patients, the prescribing error rate might decline while the overall adverse event rate goes up.

 

 

So what are we to do? We doubt anyone is likely to increase their working memory capacity (regardless of all those TV commercials you see to take product X to improve your brain function!). You might be able to impact the fatigue factor through judicious scheduling practices (and even some of the practices such as “power naps” that we’ve described in our many columns on the 12-hour shift for nurses). So we’re left largely with focusing on interruptions. Westbrook and colleagues admit that “blanket interventions aimed at reducing all interruptions are likely to be ineffective, inefficient and at times unsafe.” But they do recommend the following “targeted” interventions:

 

They also note that the application of cognitive systems engineering to ED information systems shows promise.

 

And, lest we forget, we physicians are also probably the most frequent cause for interruptions to other healthcare professionals, particularly nurses.

 

 

 

 

Prior Patient Safety Tips of the Week dealing with interruptions and distractions:

 

 

 

Some of our other columns on the role of fatigue in Patient Safety:

 

November 9, 2010      12-Hour Nursing Shifts and Patient Safety

April 26, 2011             Sleeping Air Traffic Controllers: What About Healthcare?

February 2011             Update on 12-hour Nursing Shifts

September 2011          Shiftwork and Patient Safety

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 2012               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    June 2012 Surgeon Fatigue

November 2012          The Mid-Day Nap

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014              The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift

December 2, 2014       ANA Position Statement on Nurse Fatigue

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes

September 2015          Surgery Previous Night Does Not Impact Attending Surgeon Next Day

September 6, 2016      Napping Debate Rekindled

April 18, 2017             Alarm Response and Nurse Shift Duration

July 11, 2017              The 12-Hour Shift Takes More Hits

 

 

Some of our other columns on housestaff workhour restrictions:

 

December 2008           IOM Report on Resident Work Hours

February 26, 2008       Nightmares: The Hospital at Night

January 2010               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 2011               No Improvement in Patient Safety: Why Not?

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    Surgeon Fatigue

November 2012          The Mid-Day Nap

December 10, 2013     Better Handoffs, Better Results

April 22, 2014             Impact of Resident Workhour Restrictions

January 2015               More Data on Effect of Resident Workhour Restrictions

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes

September 2015          Surgery Previous Night Does Not Impact Attending Surgeon Next Day

March 2016                 Does the Surgical Resident Hours Study Answer Anything?

 

 

 

Our previous columns on the 12-hour nursing shift:

 

November 9, 2010      12-Hour Nursing Shifts and Patient Safety

February 2011             Update on 12-hour Nursing Shifts

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014              The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift

December 2, 2014       ANA Position Statement on Nurse Fatigue

September 29, 2015    More on the 12-Hour Nursing Shift

July 11, 2017              The 12-Hour Shift Takes More Hits

 

 

 

References:

 

 

Chisholm CD, Dornfeld A, Nelson DR, Cordell WH. Work interrupted: A comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001; 38(2): 146-151

http://www.annemergmed.com/article/S0196-0644%2801%2967082-3/abstract

 

Jeanmonod R, Boyd M, Loewenthal M, Triner W. The nature of emergency department interruptions and their impact on patient satisfaction. Emerg Med J 2010; 27: 376-379

http://emj.bmj.com/content/27/5/376.abstract

 

 

Chisholm CD, Weaver CS, Whenmouth L, Giles B. A Task Analysis of Emergency Physician Activities in Academic and Community Settings. Ann Emerg Med 2011; published ahead of print January 31, 2011

http://www.annemergmed.com/article/S0196-0644%2810%2901823-8/abstract

 

 

Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency Department Workplace Interruptions Are Emergency Physicians “Interrupt-driven” and “Multitasking”? Academic Emergency Medicine 2000; 7(11): 1239–1243

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2000.tb00469.x/pdf

 

 

Friedman SM, Elinson R, Arenovich T. Emergency Physician Work, Communication and Interruptions: A Human Factors Approach. Israeli Journal of Emergency Medicine 2005; 5(3): 35-42

http://www.isrjem.org/IJEM_Aug_TimeandMotion_Proof.pdf

 

 

Westbrook JI, Coiera E, Dunsmuir WTM, et al. The impact of interruptions on clinical task completion.

http://qualitysafety.bmj.com/content/19/4/284

 

 

Westbrook JI, Raban M, Walter SR, Douglas H. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. BMJ Qual Saf 2018; 9 January 2018

http://qualitysafety.bmj.com/content/early/2018/01/09/bmjqs-2017-007333.full

 

 

 

 

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