Distractions and interruptions are frequent contributing factors to errors in any industry and especially so in healthcare. Learning to deal with them and having strategies to minimize their impact is essential. Some people are innately better than others at dealing with them. Many of us proudly tout our ability to multitask. But the bottom line is that even those who are good at multitasking are vulnerable to the effects of interruptions and distractions. Good design of work environments and workflows may help minimize distractions and interruptions and make everyone less prone to errors.
One organization recently implemented a “bundle” to reduce interruptions that may lead to medication errors (Freeman 2012). After analyzing medication errors occurring on their cardiac/thoracic stepdown unit, which might administer over 25,000 medication doses in a month, they reviewed the literature on interruptions and analyzed their own unit for factors contributing to interruptions. Their unit had both private and semiprivate rooms. The latter were more prone to interruptions given the increased traffic of providers, family and visitors.
The “bundle” of interventions they chose consisted of the following:
· Lighted lanyards (to identify an individual not to be interrupted)
· A “No Interruption Zone”
· Triage of phone calls and pages during peak medication times
· Patient/family education
· eMAR review at nurse-to-nurse handoffs
· Scripting cards to explain to patients/families the safety initiative
· Communication to all stakeholders
· Use of unlicensed assistive personnel (UAP’s) to round and respond
The lighted lanyards were chosen over several other potential methods as the means of identifying the nurse who should not be interrupted. The other methods considered were vests, hats, sashes, or lighted armbands.
Turning the medication room into a “No Interruption Zone” was also challenging. They note it is common for such rooms to have a “water cooler” atmosphere where casual conversations are common. Signage, staff education, and direct observation helped convert the “water cooler” atmosphere to more of a “sterile cockpit” atmosphere.
They used the classic PDSA quality improvement model to roll out the initiative and used a direct observation methodology to measure interruptions. The rate of interruptions during medication preparation and administration averaged 3.29 interruptions prior to implementation of the new model. After implementation the rate of interruptions dropped to 1.18. In addition, there was a change in the distribution of sources of interruption. The top 3 causes of interruptions after implementation were patients, other nurses, and pagers. Prior to the implementation family members had been the third leading cause of interruptions and these dropped dramatically. There was also a substantial decrease in the number of reported medication errors after implementation.
Sustainability is key to any quality improvement intervention. Unfortunately, there was some dropoff in adherence to all the elements of the “bundle” over time. Specifically, there was some resistance to use of the lighted lanyards and the “No Interruption Zone” regressed somewhat toward its pre-implementation milieu. Continued reminders to staff about components of the program were thus necessary.
Our August 28, 2012 Patient Safety Tip of the Week “New Care Model Copes with Interruptions Better” highlighted another innovative process redesign at University of Pittsburgh Medical Center (UPMC) that improved care while handling interruptions (Kowinsky 2012).
That’s the nursing side. There’s also been more interest in mitigating the effects of interruptions on the physician side. A new study (Campbell 2012) used direct observation of anesthetists and anesthesiologists as they cared for patients from the time the anesthetist and patient entered the anesthetic room until recovery. They found an average of 0.23 interruptions per minute overall but the interruption rate differed during various stages of the overall process. During induction there were 0.29 interruptions per minute, during transfer of the patient into the operating room 0.33 interruptions per minute, and during emergence 0.5 interruptions per minutes. During the maintenance phase of anesthesia there were only 0.15 interruptions per minute. Interruptions came from a variety of sources (internal team members, external team members, equipment-related issues, workspace design issues, noise, teaching responsibilities, patient-related problems, and items such as pagers and mobile phones).
The authors did note that not all interruptions have negative impact. In fact, 3.3% had a positive impact (i.e. the distraction or interruption facilitated either the procedure or the safety of the patient).
They also noted that some interruptions and distractions may occur together. They provide a couple examples in graphic form of how multiple interruptions and distractions may interplay and lead to either a negative or positive consequence.
They also did semi-structured interviews with the anesthetists and these were particularly helpful in identifying strategies used to manage distractions and interruptions. Several commented on the relatively high rate of distractions and interruptions during the emergence phase and felt that other team members may not understand that emergence is just as important as induction. They note that many of the other team members have finished their work on the case and fail to recognize that the anesthetist’s work in not done. (One cannot ignore the obvious analogy to aviation where takeoff and landing are the two most critical times for safety. In aviation the “sterile cockpit” procedure is used to avoid distractions and interruptions during these critical phases.)
The anesthetists in the study had 2 main strategies for coping with distractions and interruptions: 1) ignoring people and 2) asking people with non-urgent or irrelevant queries to return later. They tried to strike a balance between an assertive approach and a more proactive but less assertive approach but this was largely a function of the temperament of the individual anesthetist. But a third, more implicit, strategy was managing one’s own attention and filtering out constant distractions. They also had to recognize that they were themselves causes for distractions and interruptions for other team members at times. So changing the culture of the team and teamwork is also a key strategy. Other strategies include ergonomic elements such as redesign of workspace and avoiding the anesthesia room becoming a thoroughfare to reach the OR and organizational elements such as leaving mobile phones in the locker room.
Both these studies made good use of direct observational methodology. We’ve noted the utility of direct observation in several columns, most recently in our October 23, 2012 Patient Safety Tip of the Week “Latent Factors Lurking in the OR”.
Distractions and interruptions are a fact of life in all aspects of our work and home life. But that doesn’t mean we have to simply accept them all. Sometimes actually identifying the sources and frequency of distractions and interruptions allows us to implement strategies to avoid at least some of them.
We’ve done a number of columns on the deleterious effects of interruptions and distractions for physicians, nurses, pharmacists and others:
Freeman R, McKee S, Lee-Lehner B, Pesenecker J. Reducing Interruptions to Improve Medication Safety. Journal of Nursing Care Quality 2012; Published ahead of print POST AUTHOR CORRECTIONS, 23 October 2012
Kowinsky AM, Shovel J, McLaughlin M, et al. Separating Predictable and Unpredictable Work to Manage Interruptions and Promote Safe and Effective Work Flow. Journal of Nursing Care Quality 2012. 27(2): 109-115, April/June 2012
Campbell G, Arfanis K, Smith AF. Distraction and interruption in anaesthetic practice.
Br. J. Anaesth 2012; 109(5): 707-715
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