There is ample evidence from research in other industries and from studies in cognitive psychology that interruptions cause errors in both cognitive and executive functions. So avoiding interruptions ought to be a good patient safety strategy. On numerous occasions we have used the aviation analogy of the “sterile cockpit”. That is a concept in which interruptions and distractions are avoided during certain critical procedures such as takeoff and landing in aviation or in medication preparation or administration in healthcare.
Our August 25, 2009 Patient Safety Tip of the Week “Medication Safety: Frontline to the Rescue Again!” highlighted two studies showing how frontline nursing staff are still critical in avoiding medication errors. Both discussed the importance of avoiding interruptions and distractions.” highlighted some excellent studies on interruptions and distractions in healthcare. In that we provided references to some good statistics about the frequency and nature of interruptions and distractions and listed some recommendations about how to avoid them. We also discussed some of the cognitive research on how memory works and how interruptions affect what stays in your “working memory”, a key concept in error occurrence. Our November 3, 2009 Patient Safety Tip of the Week “
Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” noted how the lack of non-nursing staff on weekends actually adds both considerable workload and interruptions to nursing staff. We have also seen that clerical staff have often been reduced or eliminated in the recent economic downturn, further accentuating the problem of interruptions for nursing staff.
Now two new papers have been published that quantify the impact that interruptions have on clinical care. The first (Kalisch 2010) observed 35 nurses over 4-hour periods at two Midwestern hospitals. They found an average of 10 interruptions per hour (one interruption every 6 minutes) but at some hospitals the interruption rate was as high as an interruption every 4.5 minutes. Those rates are comparable to those in several studies noted in our August 25, 2009 Patient Safety Tip of the Week “ ”. Interruptions were also significantly more frequent in ICU settings than on medical/surgical units. It was also not uncommon to have multiple interruptions (eg. one interruption interrupting another). The study also looked at multitasking by nurses and found they were multitasking on average 34% of the time.
Interruptions by patients were most common (28%), followed closely by other nurses (25%). Assistive personnel and physicians accounted for 10% and 9% of interruptions. The interruptions occurred during a whole host of nursing activities but nurses were interrupted during medication administration 57% of the time at one hospital. While most interruptions were initiated by others, 36% of the interruptions were self-initiated.
The second paper (Westbrook 2010) correlated the effect of nursing interruptions on medication administration errors in 2 teaching hospitals in Australia. Overall, interruptions occurred in over half of all medication administrations and they demonstrated a clearcut relationship between number of interruptions and both procedural failures and clinical errors. Every interruption was associated with an increase of 12.1% in mean procedural failures. And each interruption was associated with an increase of 12.7% in mean clinical errors per drug administration.
Strikingly, if there were 5 interruptions during a medication round with a single patient it was virtually certain that at least one procedural failure would occur and there was a 61% chance of a clinical error occurring. And the risk of a major clinical error doubled with 4 interruptions.
Perhaps the most interesting finding in the Australian study was that part-time and less experienced nurses had lower rates of procedural failures. Some of that may have been explained by the fact that the most common procedural error in that study was failure to check the patient identification prior to administration of medication. The authors felt that experienced nurses may have been more likely to believe they could easily identify patients visibly. But, more importantly, after controlling for multiple variables they found that nurse’s experience and work status did not reduce the risk of making a clinical error. That strongly suggests external factors are major contributors to medication administration errors and that focusing on those is likely to make an impact on reducing such errors. That’s actually good news! Those who work in quality improvement and patient safety circles know that it is usually much easier to change the system than to change individual behavior.
One currently popular method of minimizing interruptions is use of a brightly colored flag of some sort to indicate a nurse should not be interrupted. In John Nance’s fictitious hospital (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) it was a red towel draped over a nurse’s left shoulder that told staff “do not interrupt me”. In others, nurses don brightly colored vests, sometimes called “interruption vests”.
It is also possible for some activities to cordon off an area and make it a “no-interruptions zone” when a nurse is preparing, dispensing, administering, or otherwise handling medications.
Interruptions are often done because of important events or activities. These are “relevant” interruptions. However, many interruptions are for activities that are irrelevant for patient care. One example is the nurse being interrupted to give directions to a family to get to the cafeteria. So you could use well-placed signage or good hospital services brochures to minimize such interruptions.
Another very common interruption is by another nurse or a physician asking about a piece of clinical information they could also get by looking at the patient’s chart. It may save them time but it interrupts you from an important task, increasing the chance of you making a mistake. Sometimes its as simple a question as “Where did Mr. Jones go?”, which might be easily handled by use of a whiteboard.
Using checklists can be very helpful in avoiding errors, as we have seen in multiple areas of healthcare. However, using another analogy from aviation, interruptions often cause items in checklists to be overlooked or bypassed. So if you do get interrupted, you need to go back over your checklist from its beginning.
One technique that has been steadily gaining acceptance in recent years is doing hourly rounds (Studer Group 2006). While these are often promoted as a means of improving patient satisfaction (which they clearly do), they also appear to be a tremendous time saver. That is because patients, knowing their nurse will be in to see them on the hour, are much less likely to press their call button. That results in fewer interruptions to nursing staff. As another bonus of hourly rounds, fall rates typically drop substantially (Meade 2006) (primarily because toileting activities can be ensured during the hourly rounds).
You don’t realize the number of interruptions until you actually count them. Your own personal productivity is clearly impacted by interruptions. Some day when you are working keep a log of interruptions. Then assign a “severity” score to them to tell you how many were important interruptions and how many were to answer things that could have been handled in a different manner. You will be amazed at the frequency of the interruptions and you can usually then rearrange your work environment to minimize the less important interruptions and make your workday more productive.
The same obviously applies to most areas of clinical care. So it is not just interruptions medication administration that are important. We’ve previously highlighted several other clinical settings where interruptions have a negative impact. During handoffs it is critical that you have enough time to allow a two-way dialog where the recipient has ample opportunity to ask questions. In the OR, it is clear that “OR traffic” (often in the form of interruptions) is a factor in increasing nosocomial infections and, we suspect, other medical errors. And we know that increased bed occupancy (either in the ER or hospital as a whole) is associated with increased risk of clinical incidents and errors. While the latter is usually associated with increased workloads, it is also likely associated with increased frequency of interruptions.
Redesigning workspaces or workflows may be very useful. A recent survery of over 1600 hospital nurses by Jackson Healthcare showed that almost three quarters of respondents spent over a quarter of their shifts on indirect patient activities. While much of that time is doing paperwork or documentation, many noted time spent walking to equipment/supply areas, utility rooms, etc. In our August 25, 2009 Patient Safety Tip of the Week “ ” we noted an article by Redding & Robinson that also noted disjointed traffic patterns often led to more interruptions, such as questions from families or caregivers, as nurses had to walk from a patient’s room to a different supply area. So one can redesign to ensure necessary supplies and equipment are kept within the patient room. Note that there may also be infection control benefits from avoiding long walks for supplies and equipment.
Sometimes simply taking the time to stand back and examine your workflows is a great patient safety exercise. If you work on reducing interruptions and distractions in your environment, we guarantee you will see not only gains in productivity and both patient and staff satisfaction but you will also see error rates decline and patient outcomes improve.
Kalisch, Beatrice J.; Aebersold, Michelle
Interruptions and Multitasking in Nursing Care. Joint Commission Journal on Quality and Patient Safety 2010; 36(3): 126-132 March 2010
Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO.
Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors
Arch Intern Med. 2010;170(8):683-690
Jackson Healthcare. Hospital Nurses Study 2010. Summary of Findings.
Redding D, Robinson S. Interruptions and Geographic Challenges to Nurses' Cognitive Workload. J Nurs Care Qual 2009; 24: 194-200
Studer Group. You Called? Hourly Rounding Cuts Call Lights. November 20, 2006.
Meade CM, Bursell AL, Ketelsen L. Effects of Nursing Rounds: on Patients' Call Light Use, Satisfaction, and Safety. AJN The American Journal of Nursing. 106(9):58-70, September 2006.