Interruptions and distractions are significant factors
contributing to errors in any industry and in patient safety events in
healthcare (as well as unintended events in your everyday life!). Our multiple
columns on the scope and impact of interruptions and distractions in healthcare
are listed at the end of today’s column.
Recovery from interruptions requires keeping in your
short-term memory several things:
Previous research also shows that study participants were
always slower to resume the primary task when they were interrupted during the
middle of a subtask than when interrupted between subtasks (Monk 2004).
But one concept we’ve never discussed is that of “nested” interruptions. Workers in
multiple industries are often interrupted during a task, move on to another
task, and then get interrupted again. They thus have to remember where they
left off in not just one task but in several tasks. This obviously leads to
vulnerability to errors. While we often tout our ability to multitask as a
positive talent that improves our efficiency, that multitasking also makes us more prone to make errors. Unintended
consequences of interruptions include not only making errors but also performing
redundant work.
Human factors researchers have delved into how interruptions
impact various task performances. A recent study showed that the scope of
interruptions and distractions is even more complicated (Sasangohar
2017). These researchers noted that ICU nurses are often interrupted
from one task to perform another task and that interruptions in the second task
are also frequent. That results in nurses having to resume not just one task
where they left off but having to resume multiple tasks at varying stages of
completion, a classic example of “nested”
interruptions.
They hypothesized “that nested interruptions tax the working
memory even more than just performing multiple secondary tasks sequentially
because the nurse would have to encode in working memory the resumption goals
for both the primary and the interrupted secondary tasks”. So they performed a
laboratory study with 30 ICU nurses performing an electronic order-entry task
under three interruption conditions:
Their results confirmed that the nested interruptions
resulted in significantly longer primary-task resumption lag and less accurate
task resumption compared with both the serial interruption and baseline conditions.
While a primary goal should be to minimize interruptions and
distractions, we need to recognize that some interruptions may be unavoidable
(and some even positive) and take steps to mitigate
the impact of such interruptions on tasks. And we clearly need ways to
recognize all the tasks needing completion, not just the one most recently
interrupted.
One such mechanism for mitigation is use of technology to
help us return to our previous task(s). As we write this column we are often
interrupted by numerous external sources (phone calls, comments from others,
etc.) and internal sources (other topics popping up, coffee or bathroom breaks,
etc.). For example, we may suddenly think about something we want to include in
a separate column on a related or even different topic. We jump to that other
draft column but then have to return to the original column. Thank goodness we
usually have a blinking cursor that helps reorient us to where we had left off!
And some word processors allow you to re-open a saved document to the location
you had most recently left off when saving that document. And if we are really
meticulous, we’ll leave a bookmark of some sort to redirect us to where we left
off. But even using these technological tools to help mitigate the impact of
interruptions there is often a cascade of events (just as we see in virtually
all serious patient safety events) that can lead to unwanted consequences. For
example, a power failure can in seconds overcome all those safety barriers you
just put in place.
So why not use technology to mitigate the impact of
interruptions in healthcare? For example, virtually all EHR’s (electronic
health records) and CPOE (computerized physician order entry) or e-prescribing
or related IT systems have automatic time out protocols built in. That means
that after x minutes of inactivity the user is automatically logged out. The
technology exists that would allow for a text message to be sent to the user at
the time of automatic time out indicating that some activity may have gone
unfinished and then put that user on the appropriate screen once they log back
in.
Such use of technology might well be beneficial in reducing
interruption-related errors related to computerized functions. But what about
other tasks? Nurses already utilize a number of behavioral mechanisms to mitigate the impact of interruptions. An
excellent 2010 observational study of ICU nurses (Grundgeiger
2010), using a mobile eye tracker to measure the task resumption lag
and other parameters, found that in 37.6% of all interruptions, nurses used a
behavioral strategy to reduce or avoid individual prospective memory demands.
For example, nurses sometimes decided to finish primary tasks before attending
to the interrupting task. In other instances, nurses used artifacts such as syringes, cables, equipment for blood
samples, or blood gas analysis result sheets in their hands while attending to
the interrupting task (the artifacts being part of the primary task that needed
to be resumed). And sometimes nurses placed reminders in an obvious position to help them resume the
interrupted primary task later, such as putting utensils to take a blood sample
on the medication desk. They also observed some general strategies nurses used
to remind themselves about forgotten interrupted tasks. Examples include scanning
the top of the bed area while washing hands, looking at places where artifacts
are generally placed, accessing the clinical information system, or writing
paper notes.
Their data suggests that nurses remembered documentation
tasks more frequently than expected without applying a behavioral strategy and
less frequently by holding an artifact but if medication tasks or cleaning up
tasks were interrupted, a task artifact was held in the hand while serving the
interruption more frequently than expected.
Some other factors were related to lags in resumption of
tasks. Length of the interruption had a significant positive correlation with resumption
lags (longer interruptions result in longer resumption times). And context cues
were important. It was anticipated that if an interrupting task required the nurse
to change location and leave the context in which the goal was encoded, resumption
lags would increase because the contextual cues are missing. Indeed, they found
that such change of context had a significant effect on resumption times,
likely because “the context change may have changed environmental cues, which
in turn may have triggered retrieval of task demands other than the to-be
resumed task, causing longer resumption times”.
Another study by Sasangohar and colleagues (Sasangohar
2015) found that ICU nurses
spent about 50% of their time conducting medium-severity tasks (e.g.,
documentation), 35% conducting high-severity tasks (e.g., procedure), and 14%
conducting low-severity tasks (e.g., general care). They found that the rate of
interruptions with personal content observed during low-severity tasks was
higher than the rate during high- and medium-severity tasks, suggesting that interrupters
might have evaluated task severity before interrupting. The authors propose
that increasing the transparency of the nature and severity of the task being
performed may help others further modulate when and how they interrupt a nurse
and that, rather than try to eliminate all interruptions, mitigation strategies
should consider the relevance of interruptions to a task or patient as well as
their urgency.
There is one such high-severity task for which such
transparency is often already used: medication administration. The nursing
activity perhaps most studied with regard to interruptions is medication
administration and there have been multiple studies aimed at reducing such
interruptions during medication administration. A recent study in a large
teaching hospital in Australia looked at the impact of a ‘Do not interrupt’
bundled intervention to reduce non-medication-related interruptions to nurses
during medication administration (Westbrook
2017).
The Westbrook study confirmed a very high rate of
interruptions during medication administration. At baseline, they found a rate
of 57 interruptions for every 100 medication administrations and 87.9% of the
interruptions were not related to medication administration. The majority of
the interruptions were from other nurses and pertained to other patients.
Interestingly, requests from patients and social interruptions each accounted
for only about 10% of interruptions.
The bundled intervention in the Westrbrook
study consisted of:
Results of the intervention showed modest reductions in
interruption rates. The average rate of interruptions was reduced from 56/100
to 38/100 administrations on the intervention units compared with little change
on the control units. Most of the reduction was from reducing interruptions
from other nurses. There was no change in interruptions from patients.
The study did not report medication error rates. However, it
used data from other studies to extrapolate the potential reduction in
medication administration errors and estimated that rate as 1.8%. They noted
that compared unfavorably to the literature reduction in medication errors of
14% by implementation of an electronic medication administration record.
The post-intervention survey of nurses was particularly
telling. While most nurses recognized the importance of interruptions on
medication errors, a surprising number expressed their opinion they did not
think the intervention should continue. Many noted that donning and wearing the
vest was cumbersome and led to longer durations for medication administration.
As we’ve noted before, it is not enough to simply use a reduction
in interruptions as the primary outcome measure in such studies. And it’s not
even enough to measure reductions in medication errors as the only outcome. We
must measure other patient safety outcomes as well. That is because not all
interruptions have negative impacts. Clearly some interruptions are important
and have a positive impact on patient safety. In the Westbrook study the
majority of interruptions were by other nurses and pertained to questions about
other patients. Presumably, some of those interruptions would be expected to
have had a positive impact on those other patients.
In our November 8,
2016 Patient Safety Tip of the Week “Managing
Distractions and Interruptions” we noted a study which sought to help differentiate the “good”
interruptions from the “bad” ones (Myers 2016).
They found that, on average, nurses were interrupted every 11 min, with
20.3% of their workload triggered by interruptions. Those figures are
comparable to most other studies on nursing interruptions. They then developed
a statistical model which showed that alarms and call lights returning nurses’
attention to the patient outside the patient room are beneficial, while
interruptions in the patient room are generally detrimental. Beneficial
interruptions are those that return the nurse’s focus to the patient and those
supporting patient-clinician and clinician-clinician communications. A previous
study by Sasangohar and colleagues also identified
the inconsistencies in the way interruptions are defined and categorized
potential sources of negative and positive interruptions (Sasangohar 2012).
Our November 8, 2016
Patient Safety Tip of the Week “Managing
Distractions and Interruptions” summarized many of the interventions that have been implemented to
minimize or mitigate impact of interruptions and distractions. And we again
refer you back to the article by Flynn et al (Flynn 2016)
that did an excellent job of
summarizing the literature on interruptions and their impact on medication
administration and chronicling those interventions which are evidence-based.
Prior Patient Safety
Tips of the Week dealing with interruptions and distractions:
References:
Monk CA, Boehm-Davis DA, Trafton,
JG. Recovering from interruptions: Implications for driver distraction
research. Human Factors 2004; 46: 650-663
https://www.interruptions.net/literature/Monk-HF04.pdf
Sasangohar F, Donmez
B, Easty AC, Trbovich PL.
Effects of Nested Interruptions on Task Resumption. A Laboratory Study with
Intensive Care Nurses. Human Factors: The Journal of the Human Factors and
Ergonomics Society 2017; First Published January 27, 2017
http://journals.sagepub.com/doi/abs/10.1177/0018720816689513?journalCode=hfsa
Grundgeiger T, Sanderson P,
MacDougall HG, Venkatesh B. Interruption Management
in the Intensive Care Unit: Predicting Resumption Times and Assessing
Distributed Support. Journal of Experimental Psychology: Applied 2010; 16(4):
317-334
https://interruptions.net/literature/Grundgeiger-JEPA10.pdf
Sasangohar F, Donmez
B, Easty AC, Trbovich PL. The
relationship between interruption content and interrupted task severity in
intensive care nursing: An observational study. International Journal of
Nursing Studies 2015; 52: 1573-1581
http://www.journalofnursingstudies.com/article/S0020-7489(15)00196-0/abstract
Westbrook JI, Li L, Hooper TD, et
al. Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce
interruptions during medication administration: a cluster randomised
controlled feasibility study. BMJ Qual Saf 2017; 0: 1-9 published online first 23 February 2017
http://qualitysafety.bmj.com/content/early/2017/02/23/bmjqs-2016-006123
Myers RA, McCarthy MC, Whitlatch
A, Parikh PJ. Differentiating between detrimental and beneficial interruptions:
a mixed-methods study. BMJ Qual Saf
2016; 25: 881-888 Published Online First: 16 November 2015
http://qualitysafety.bmj.com/content/25/11/881
Sasangohar F, Donmez
B, Trbovich P, Easty AC, Not
all interruptions are created equal: Positive interruptions in healthcare. In Proceedings
of the Human Factors and Ergonomics Society 56th Annual Meeting (pp. 824-828). Santa
Monica, CA: Human Factors and Ergonomics Society 2012
http://journals.sagepub.com/doi/10.1177/1071181312561172
Flynn F, Evanish JQ, Fernald JM, et al. Progressive Care
Nurses Improving Patient Safety by Limiting Interruptions During Medication
Administration. Crit Care Nurse 2016; 36: 19-35
http://ccn.aacnjournals.org/content/36/4/19.full.pdf+html
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