We’ve done lots of columns on the negative impact of distractions and interruptions on patient safety. Our most recent column on distractions and interruptions (see our August 30, 2016 Patient Safety Tip of the Week “”) summarized some of the evidence-based interventions used to minimize the negative impact of interruptions and distractions.
But not all interruptions are detrimental. In fact, many interruptions alert healthcare personnel to urgent patient care needs and have a positive impact on patient safety. The key, therefore, is determining which interruptions are potentially beneficial and avoiding the ones that are likely detrimental.
A new study, using a mixed methods approach, 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.
Another timely paper has good suggestions regarding ways to minimize detrimental interruptions (Bravo 2016). The authors combined data from 2 of their previous studies comparing medication passes without recorded interruptions or distractions to those which had interruptions and/or distractions. Of those patients, the average number of interruptions/distractions was 1.4 per patient. The interruptions were dichotomized into “routine” or “urgent”. The “urgent” interruptions comprised 8.3% of the total number of interruptions.
In the studies by Bravo et al. the most frequent sites of interruptions were the bedside (46%) and medication room (27%). At the bedside, the types of interruptions were need for patient and/or family education, patient request for toileting assistance, and coordination of patient schedules with other members of the health care team. Problematic in the medication room was miscellaneous banter by other nurses unrelated to medication administration protocols. The third most common site for interruptions was the hospital unit (13.5%) and an example given was a nurse moving toward a patient room to administer medications being interrupted by another healthcare provider to give additional patient orders or to clarify patient status. Initiators of the interruptions were other nurses (43%), other members of the healthcare team (25%), patients (18%), and family/visitors (7.6%).
The Bravo article focuses on two key strategies to minimize the risk of distractions and interruptions:
The programmed script, as exemplified in a study from Duke (Williams 2014), should include a statement about the need to avoid unnecessary interruptions during medication administration as a patient safety feature and should also include clear language to assure patients/families that their needs and concerns are still important.
The “3 D’s” are “DEFLECT”, “DEFER”, and “DETERMINE”. Deflection is modifying or managing the need so it is no longer an issue for the patient/family. Deferring is briefly postponing something that will be handled later by the nurse (and communicating this to the patient). Determining is seeing if someone else can safely assist with the patient need.
A third key strategy is coordinating other patient care with the medication administration process. For example, one of the commonest interruptions is patient requests for assistance in toileting. So a strategy might be to ask a care assistant to attend to the patient’s toileting needs. We’ve also noted how hourly rounding programs can help attend to such needs so a nurse would not be interrupted during medication rounds.
Bravo et al. also recommend asking patients about their preferred liquid for taking oral medications. In our August 30, 2016 Patient Safety Tip of the Week “” we noted nurses having to stop and get water or a cup for the patient as a frequent source of interruptions. So knowing ahead of time how to facilitate a patient taking an oral medication and having the appropriate supply available can help minimize such a distraction or interruption.
Interestingly, the Bravo article does not focus on reduction in phone calls, an intervention important in the study by Flynn et al (Flynn 2016) noted in our August 30, 2016 Patient Safety Tip of the Week “” and in the Duke study (Williams 2014).
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:
The Flynn article nicely outlines in tabular form with annotations the numerous studies in the literature on the impact of interruptions.
And we’d like to remind all again about an important point that dovetails with the discussion of beneficial vs. detrimental interruptions. Most studies on interruptions during the medication administration process use only the medication error rate as the patient outcome parameter measured. The total adverse event rate should also be reported in such studies to ensure that the interventions do not have unintended consequences on aspects of care other than medication safety.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
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
Bravo K, Cochran G, Barrett R. Nursing Strategies to Increase Medication Safety in Inpatient Settings. Journal of Nursing Care Quality 2016; 31(4): 335-341
Williams T, King MW, Thompson JA, Champagne MT. Implementing evidence-based medication safety interventions on a progressive care unit. Am J Nurs 2014; 114(11): 53-62
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