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).
.
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:
- limiting unnecessary interruptions
through greater training about their potential effects
- identifying reasons, and reducing
the need, for interruptions, for example, by making required information
easily available
- redesigning work spaces
to allow clinicians to perform more demanding cognitive tasks in areas
less open to interruption
- introducing tools,
including information technology, which can provide cues to allow more
effective recovery from interruptions
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:
- August
25, 2009 “Interruptions,
Distractions, Inattention…Oops!”
- November
3, 2009 “Medication
Safety: Frontline to the Rescue Again!”
- December
15, 2009 “The
Weekend Effect”
- May
4, 2010 “More
on the Impact of Interruptions”
- October 12, 2010 “Slowing
Down in the OR”
- March
8, 2011 “Yes,
Physicians Get Interrupted Too!”
- July 31, 2012 “Surgical
Case Duration and Miscommunications”
- August 28, 2012 “New
Care Model Copes with Interruptions Better”
- November 27, 2012 “Dealing
with Distractions”
- April 16, 2013 “Distracted
While Texting”
- May 21, 2013 “Perioperative
Distractions”
- July 1, 2014 “Interruptions
and Radiologists”
- November 2014 “More
Radiologist Interruptions”
- March 17, 2015 “Distractions
in the OR”
- July 21, 2015 “Avoiding
Distractions in the OR”
- August 30, 2016 “Can
You Really Limit Interruptions?”
- November 8, 2016 “Managing
Distractions and Interruptions”
- March 7, 2017 “Nested
Interruptions”
- April 11, 2017 “Interruptions:
The Ones We Forget About”
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, 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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