Several of our columns devoted to analogies between medicine and aviation have discussed the “sterile cockpit” concept (see our Patient Safety Tips of the Week for October 2, 2007 “Learning from Tragedies. Part II”). This, of course, means that during certain procedures that require meticulous attention there should be no competing activities or conversations that might distract the pilot or healthcare worker from the task at hand.” and May 26, 2009 “
Two recent papers have dealt with the issue of distractions and interruptions and how these have continued to cause even the best healthcare workers to make some of the deadliest errors. The August 2009 issue of the ISMP Medication Safety Alert! NurseAdvise-ERR contains an outstanding article on “inattentional blindness”. It’s actually a good human factors article in terms understandable by those who do not have a Ph.D. in psychology.
It begins with real-life examples where intelligent, hardworking, dedicated healthcare workers do things like draw up and administer a 1000-fold overdose of heparin. The article describes how our brains filter innumerable bits of information to select just a few to keep in our consciousness and how the brain also “fills in the gaps” (a form of confirmation bias). It discusses the factors that shape what you attend to. Most importantly, it tells you what error-reduction strategies won’t work for this type of problem (education, training, rules) and encourages you to shift your efforts to decreasing diversions and increasing the conspicuity of critical information. Its reference list has some useful classic articles and also contains a link to the FAA Human Factors course online.
The second article (Redding & Robinson 2009) looked at “Interruptions and Geographic Challenges to Nurses’ Cognitive Workload”. The researchers actually followed nurses around during their shift and recorded all distractions and interruptions they had plus all physical and geographic challenges that interrupted or delayed their patient care tasks. The interruptions they found fell into the following categories:
The interruptions from coworkers were very often irrelevant from a patient care standpoint or were inquiries for patient information that could have been obtained from the medical record. The peripheral conversations were often ones in which the nurse was not even a participant. The phone calls were often from physicians (for orders or getting updates) but also included personal phone calls. Questions from family members were frequent interruptions and included not only questions about the patient but also things like directions to other locations in the hospital.
The geographic obstacles and traffic patterns may have been more unique to the facility. However, the most salient point is that the disjointed traffic flow often led to other distractions and interruptions like questions from other caregivers or families.
Redding and Robinson had several practical recommendations to minimize interruptions and distractions. One that we often use deals with interruptions by patients’ family members. This may be especially problematic when families are large or geographically dispersed or even dysfunctional. That is having the family (with the patient’s permission, of course) designate one “point person” who will serve as the communication liaison. You can then meet in a scheduled manner with that liaison who, in turn, can talk to the other family members. (Just keep in mind the potentially unintended consequence of the story changing as it passes through the chain of family members.) Another option is using scheduled meetings with the whole family. A third more creative solution is use of a secure website where family with designated access can get regular updates.
They also had useful suggestions for managing phone calls, ranging from triage systems for phone calls to use of hands-free wireless devices actually carried by nurses (be wary of the latter – see the discussion below on synchronous vs. asynchronous communication). They also had practical recommendations about keeping certain commonly used supplies right in the patient rooms and other suggestions about physical plant design.
And, perhaps most important, are their recommendations for hourly patient rounds. During these rounds they anticipate problems and ask patients about toileting needs, pain control, position changes, food/water, etc. And simply telling the patient when they would be back next often reduced the frequent use of the nurse call buttons.
They did also note other research that recommended use of visual signals such as a hat or apron with the words “Please do not interrupt” during certain activities. One of the most interesting concepts we saw in John Nance’s book “Why Hospitals Should Fly” (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) was his description of a nurse preparing medications with a red towel over her left shoulder to signify “do not disturb”.
Redding and Robinson documented 244 interruptions while observing 32 nurses for one hour each (7.6 interruptions per hour). Prior research showed nurses experience an average of 3.4 interruptions per hour (Wolf 2006), 6.3 per hour (Ebright 2003) so all these studies are consistent.
Travel patterns may influence the nature of the interruptions. Ebright noted that a nurse whose patients were dispersed had about the same number of interruptions as one whose patients were clustered. However, whereas half the interruptions for the “clustered” nurse were from her own patients, almost all the interruptions for the “dispersed” nurse were from people other than her patients.
Remember, many interruptions are “two-way”. That is, one healthcare worker needs to interrupt his/her routine to ask another healthcare worker a question (thus interrupting that worker as well). So some of your solutions could have a “double” return on investment.
Our old friend the checklist is a good way to help you remember items to do in a structured process. However, one problem often noted in aviation is that pilots forget where they were in their checklist after an interruption. So sometimes you need to go through the whole checklist again.
If you are interested in learning further about cognitive psychology, one of the best articles on how interruptions and distractions interfere with working memory and result in errors was in JAMIA almost 10 years ago (Parker & Coiera 2000). That article nicely describes how “working memory” differs from long-term memory. Working memory is what we use in most daily tasks (though, as you know from many of our other columns some frequently performed tasks are actually done at a subconscious level and may never even reach working memory). But working memory has significant limiations. Intrusion of another plan or task can cause one to forget a task in as little as 10 seconds. In addition, without conscious attention, accurate memories in working memory only last about 20 seconds.
They also emphasize 2 other concepts: the primacy effect and the recency effect. The primacy effect means you tend to recall best those items that have been in working memory the longest. The recency effect means you tend to recall best those things that were added most recently to working memory. Some distractions may obliterate the recency effect but not the primacy effect. Also, because of these two effects, those items that were in the “middle” of your task list are most likely lost due to interruptions or distractions. And the more “new” plans you force into working memory displaces all but the oldest plans.
Parker and Coiera talk about the promise of asynchronous means of communication (e-mail, voice mail, etc.) as a means of reducing interruptions. Allowing noncritical questions to be answered at the recipient’s convenience certainly can result in fewer interruptions. But it may also cause other inefficiencies, as we all see our email inboxes getting bloated. But they caution about some other new technologies (wireless phones) that actually make individuals too accessible and thus even more prone to interruptions. And we all know about the rash of traffic accidents occurring as drivers are text messaging while driving. In healthcare, text messaging has the double jeopardy of causing both interruptions and distractions plus using abbreviations that may be ambiguous and dangerous.
At any rate, a cultural change is required if we are going to reduce the adverse effects of interruptions and distractions. Certainly, face-to-face conversations are important in fulfilling social needs and promoting teamwork and camaraderie. They may also be critical when one needs confirmation that the message was both received and understood (i.e. hearback). But the cultural change is really adopting the culture of safety in which everyone recognizes what activities and situations are high risk and respecting the “sterile cockpit” during those activities. There is a little bit of “selfishness” in all of us that fosters the culture of interruption. We all think our current activity is the most important one. And we are all guilty. Last week I interrupted the head nurse on a unit to do “catheter rounds”. I never thought to ask or observe what task she was doing when I interrupted her. It would make a lot more sense to schedule a time each day to do those catheter rounds. Then no one would have to be interrupted from other equally important tasks.
By the way, try the exercise of recording interruptions and distractions in your own life – whether it is the patient care part of your work or the administrative part of your work or simply the rest of your daily life. You’ll be surprised at how often you are interrupted or distracted! No wonder we all make mistakes! By documenting when, how often, by whom, the activity we were doing, and under what circumstances the interruption occurred we can develop our own strategies to minimize interruptions and distractions during critical periods.
For example, if you find that many of your interruptions occur because you must take a particular route to get certain equipment or supplies, you can redesign the physical space to put the supplies in a different location (but beware of unintended consequences of your redesign!). If your interruptions tend to occur while you are doing a handoff activity, you may have to move your handoff activity to a room with a “Do Not Disturb” sign on the door. Get creative! Put an “On the Air” sign (like a radio/TV studio uses) over your door and light it up when you don’t want to be disturbed. And if it is one colleague who you legitimately need to interact with that tends to interrupt the most, consider a daily scheduled meeting so you can still deal with all their needs but avoid interruptions at the wrong time. And many of your interruptions are for information that is inadequately made available elsewhere (“Hey, who’s on call for neurology today?” could be avoided if you kept an accurate list available in places everyone knows to look).
Update: See our May 4, 2010 Patient Safety Tip of the Week “More on the Impact of Interruptions”.
ISMP. Inattentional blindness: What captures your attention? ISMP Medication Safety Alert! NurseAdvise-ERR August 2009
FAA. Human Factors Course On-line.
Redding D, Robinson S. Interruptions and Geographic Challenges to Nurses' Cognitive Workload. J Nurs Care Qual 2009; 24: 194-200
Wolf LD, Potter P, Sledge JA, Boxerman SB, Grayson D,
Evanoff B.Describing Nurses' Work: Combining Quantitative and Qualitative
Human Factors 2006; 48: 5-14
Ebright PR, Patterson ES, Chalko BA, Render ML. Understanding the Complexity of Registered Nurse Work in Acute Care Settings. Journal of Nursing Administration 2003; 33(12):630-638
Parker J, Coiera E. Improving Clinical Communication: A View from Psychology.
J Am Med Inform Assoc 2000; 7: 453-461