Work Interruptions and Their Contribution to Medication Administration Errors: An Evidence Review

Effectiveness of an improvement programme to prevent interruptions during medication administration in a paediatric hospital: a preintervention-postintervention study

OBJECTIVE

To assess the effectiveness of an improvement programme to reduce the number of interruptions during the medication administration process in a paediatric hospital.

DESIGN AND METHODS

A prestudy-post study design was used to monitor nursing interruptions during medication cycles in a paediatric hospital. Interruptions were reported on an observation sheet (MADOS-P) adapted to the paediatric context.

SETTING

A 600-bed tertiary paediatric research hospital in Italy.

INTERVENTION

The interventions included a yellow sash worn by nurses during medication cycles, a yellow-taped floor area indicating the 'No interruption area', visual notices in the medication areas, education sessions for healthcare providers and families, patient and parent information material.

RESULTS

225 medication cycles were observed before the intervention (T0) and 261 after the intervention (T1). The median of interruptions occurring in each cycle decreased significantly from baseline to postintervention (8.0 vs 2.0, p=0.002), as the rate ratios (interruptions/patient post-pre ratio: 0.34; interruptions/medication post-pre ratio: 0.37; interruptions/hour of medication cycle post-pre ratio: 0.53, p<0.001). During preintervention, the main causes of interruptions were 'other patients' (19.9%), 'other nurses' (17.2%) and 'conversation' (15.7%); during postintervention, they were 'other nurses' (26.1%), 'conversation' (18.2%) and 'other patients' (17.4%).

CONCLUSIONS

This bundle of interventions proved to be an effective improvement programme to prevent interruptions during medication administration in a paediatric context.

Interruptions and medication administration in critical care

BACKGROUND

Medication administration has inherent risks, with errors having enormous impact on the quality and efficiency of patient care, particularly in relation to experience, outcomes and safety. Nurses are pivotal to the medication administration process and therefore must demonstrate safe and reliable practice. However, interruptions can lead to mistakes and omissions.

AIM

To critique and synthesize the existing literature relating to the impact that interruptions have during medication administration within the paediatric critical care (PCC) setting.

SEARCH STRATEGY

Key terms identified from background literature were used to search three electronic databases (Medline, CINHAL and BNI). Selected sources were critically appraised using the Critical Appraisal Skills Programme (CASP) tool.

FINDINGS

There is confusion within the literature concerning the definition of interruption. Moreover, an assumption that all interruptions have a negative impact on patient safety exists. The literature identifies the multi-dimensional nature of interruptions and their impact on medication administration and patient safety. The cumulative effect of interruptions depends on what type of task is being completed, when it occurs, what the interruption is and which method of handling is utilized. A conceptual schema has been developed in order to explicate the themes and concepts that emerged.

CONCLUSIONS

This review summarizes debates within the international arena concerning the impact of interruptions on medication administration. However, conclusions drawn appear applicable in relation to practice, education and future research to other critical care settings.

RELEVANCE TO CLINICAL PRACTICE

Findings show that no single strategy is likely to improve the negative effect of interruptions without focus on patient safety. Practice education to improve team building interactions is required that equips nurses with the skills in managing interruptions and delegating high priority secondary tasks.

Inbox Messaging: an effective tool for minimizing non-urgent paging related interruptions in hospital medicine provider workflow

Communication is one of the foundations on which safe, high quality care is built.^{1, 3, 6, 17, 20} The nature of hospital medicine requires that nurses and providers be efficient and effective in communicating with multiple disciplines.¹⁷ This need for timely communication must continually be balanced with the need to minimize interruptions in workflow.^{1,2 3,4,6,7,9,13,15,17,18} Interruptions not only lead to distraction, they also add inefficiency to the care process and have been shown to contribute to an increased risk of medical error.^{2,3,4,7,17,18} A major source of interruptions are pagers that emit an audible tone with each message received.^3,9,10,17,18 This interruptive nature makes pagers a less-than-ideal tool for communicating non-urgent (address within one hour) messages received.^3,9,10,17,18 In addition to increasing interruptions, pagers do not facilitate closed loop communication, another feature that has been shown to improve safety.^14,17,25

Inbox Messaging is intended to provide a less disruptive closed-loop method of communication for non-urgent messages.

Inbox Messaging is an interface within the electronic health record (EHR) that functions similarly to e-mail. A multi-disciplinary communication workgroup identified this interface as having potential to not only decrease interruptions, but to also facilitate closed-loop communication. Inbox is currently utilized between the hours of 0700 and 1800 for non-urgent nurse-provider communication about patients on the hospital medicine service. The number of RN non-urgent pages per day was 103 (SD=19, n=97) prior to the Inbox intervention, with a significant decrease (p<.001) during follow-up to 38 (SD=14, n=354) pages per day. At the same time, the number of messages per day increased from 0 to 80 (SD=20, n=354) messages during follow-up. As desired, the mean number of RN urgent pages was unchanged from 13 per day to 13 per day (p=.52).

Cerner Inbox Messaging decreases the frequency of non-urgent pager-related interruptions in workflow.

Traditions of research into interruptions in healthcare: A conceptual review

BACKGROUND

Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations.

OBJECTIVE

To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research.

METHODS

A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community's motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community.

RESULTS

A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities.

CONCLUSIONS

Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions.

The effect of hospital unit layout on nurse walking behavior

OBJECTIVE

To confirm a new method for the research question, "How do different hospital unit layouts affect nurses' walking behavior and distance?"

BACKGROUND

Concern is renewed regarding nurses' long walking distances because of the trend toward larger patient rooms with family areas inside, resulting in a larger overall unit size. Studies have found unit design characteristics that support nurses' efficient walking, but few have done it in units designed for patient- and family-centered care. To examine the effect of unit design on nurses' walking behavior, the authors propose a new method of observing a specific task.

METHODS

The authors observed nurses during the task of medication administration.

RESULTS

Contrary to their hypotheses, results showed: (1) Experienced nurses had more unnecessary stops and longer walking distances than new nurses because of interactions; and (2) nurses in the smaller wing of the unit walked more than those in the larger wing of the same unit. The authors posit that the closeness between the nurses' path to the medication supply room and the central nurses' station affected the frequency of interactions and prompted a deviation from the shortest and most efficient path during medication administration.

CONCLUSION

Observing a specific task to identify the effect of unit layout was effective, determining that overall unit shape or unit layout type might not be a good predictor of nurses' walking behavior; instead the characteristics of the path that connects functional spaces such as patient room and medication area might better predict nurses' walking behavior.

Production practices affecting worker task demands in concrete operations: A case study

BACKGROUND

Construction work involves significant physical, mental, and temporal task demands. Excessive task demands can have negative consequences for safety, errors and production.

OBJECTIVE

This exploratory study investigates the magnitude and sources of task demands on a concrete operation, and examines the effect of the production practices on the workers' task demands.

METHODS

The NASA Task Load Index was used to measure the perceived task demands of two work crews. The operation involved the construction of a cast-in-place concrete building under high schedule pressures. Interviews with each crew member were used to identify the main sources of the perceived demands. Extensive field observations and interviews with the supervisors and crews identified the production practices.

RESULTS

The workers perceived different level of task demands depending on their role. The production practices influenced the task demands in two ways: (1) practices related to work organization, task design, resource management, and crew management mitigated the task demands; and (2) other practices related to work planning and crew management increased the crew's ability to cope with and adapt to high task demands.

CONCLUSIONS

The findings identify production practices that regulate the workers' task demands. The effect of task demands on performance is mitigated by the ability to cope with high demands.

When the phone rings - factors influencing its impact on the experience of patients and healthcare workers during primary care consultation: a qualitative study

Background

In the primary health care setting, patients interact directly with their healthcare workers (HCW), which include their primary physicians, nurses and pharmacists. Studies have shown that such interactions, when interrupted by phone calls received by either party, can lead to adverse outcomes and negative experiences. There is insufficient data however on the factors affecting the reaction and responses of both patients and HCWs when phone calls occur amidst their interaction. Understanding these factors will allow for the introduction of targeted measures to mitigate the negative impact of such interruptions and improve patient-HCW relationships. This study therefore aims to understand the impact of unplanned phone calls during primary health care consultations on patient–HCW interactions and the factors affecting the patient and the HCW responses.

Method

This study used focus group discussions (FGD) to gather qualitative data from patients and HCWs who had visited or worked in a major public primary healthcare institution in Singapore. The FGDs were audio-recorded, transcribed, audited and analyzed using standard content analysis to identify emergent themes.

Results

15 patients and 16 HCWs participated in 5 FGDs. The key themes that emerged from these FGDs were patients’ and HCWs’ attitudes toward professionalism and respect, task and thought interruption, call characteristics, the impact on patient safety and stakeholders’ experiences. Phone calls during consultations answered by either party often resulted in the answering party feeling apologetic and would usually keep the phone conversations short as a sign of respect to the other party. Both stakeholders valued the consultation time and similarly reported negative experiences if the phone-call interruptions became prolonged. Calls from the desk phone answered by HCWs were perceived by most patients to be relevant to healthcare services, with the assumption that HCWs exercised professionalism and would not attend to personal calls during their clinical duties.HCWs expressed their concerns and distress about potential medical errors due to phone-calls interrupting their clinical tasks and thinking processes. However, they acknowledged that these same phone-calls were important to allow clarifications of instructions and improved the safety of other patients.

Conclusion

Phone interruptions affected patient and HCW interaction during consultations and factors leading to their adverse reactions need to be recognized and addressed.

Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses' Medication Administration Processes and Systems (the MAPS Study)

Context

Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.

Aim

To identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions.

Methods

We used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures.

Findings

Overall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses’ inherent behaviour; we grouped these behaviours into ‘task focused’, and ‘patient-interaction focused’. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a ‘double-checker’.

Conclusions

We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.

"I Am Administering Medication-Please Do Not Interrupt Me": Red Tabards Preventing Interruptions as Perceived by Surgical Patients

INTRODUCTION

The recent introduction of red tabards aimed at avoiding interruptions during medication rounds has generated scientific and media debate, which is still ongoing. The principal aim of this study was to evaluate patients' perceptions of 3 different red tabards; the secondary aim was to explore individual factors associated with the negative perceptions that emerged.

METHODS

Eligible patients had to be admitted to the selected general surgical department and give written informed consent. A total of 104 patients were interviewed. Three real-sized red tabards, made with laminated paper and displaying different messages, were shown over 3 days to each patient involved.

RESULTS

Despite displaying different messages, from asking everyone not to disturb to allowing only patients to interrupt, patients perceived the tabards as directed at themselves. A different risk of preventing patients from communicating urgent needs emerged. The first tabard I am administering medication-Please do not interrupt me was most at risk to inhibit the patient. A negative impact was reported by 44 patients (42.3%) for the first tabard, 50 (48.0%) for the second tabard, and 40 (38.4%) for the third. In the logistic regression, only 2 independent factors were significantly associated with the negative perception of the message reported on the tabards: a positive attitude to interrupting nurses and receiving medication during their time in hospital. However, the variance explained by these factors ranges from 9.4% to 18.3%.

CONCLUSIONS

On the basis of the findings that emerged, the adoption of the tabards should be evaluated considering the benefits already documented, and the potential negative effects that emerged on patients, which may be influenced by cultural and linguistic aspects. Wearing the tabard with the message reported on the back, directed to the staff and not the patients, may have less negative effects on patients; in addition, using a different color not to alarm the patients may be useful. In addition, comparing the red tabard effects with other strategies introduced to deal with avoidable interruptions (e.g., "no interruption zone") to gain a comprehensive picture regarding benefits/harm is also important.

Medication-administration errors in an urban mental health hospital: a direct observation study

In the present study, we aimed to identify the incidence, type, and potential clinical consequence of medication-administration errors made in a mental health hospital, and to investigate factors that might increase the risk of error. A prospective, direct observational technique was used to collect data from nurse medication rounds on each of the hospital's 43 inpatient wards. Regression analysis was used to identify potential error predictors. During the 172 medication rounds observed, 139 errors were detected in 4177 (3.3%) opportunities. The most common error was incorrect dose omission (52/139, 37%). Other common errors included incorrect dose (25/139, 18%), incorrect form (16/139, 12%), and incorrect time (12/139, 9%). Fifteen (11%) of the errors were of serious clinical severity; the rest were of negligible or minor severity. Factors that increased the risk of error included the nurse interrupting the medication round to attend to another activity, an increased number of 'when required' doses of medication administered, a higher number of patients on the ward, and an increased number of doses of medication due. These findings suggest that providers of inpatient mental health-care services should adopt medicine-administration systems that minimize task interruption and the use of 'when required' medication, as well as taking steps to reduce nursing workload.

A comparison of human versus virtual interruptions

Although a wealth of research has examined the effects of virtual interruptions, human-initiated interruptions are common in many work settings. An experiment compared performance on a primary data-entry task during human-initiated (human) versus computer-initiated (virtual) interruptions. Participants completed blocks of trials that featured either an interruption from a computer or an interruption from a human experimenter. The timing of the onset of the interruptions was also varied across trials. Human interruptions resulted in much shorter interruption lags. No significant differences were observed for the number of correct responses on the primary task for human versus virtual interruptions, but interruptions that occurred later in the task sequence resulted in fewer mistakes. The social aspect of human interruptions may have attenuated interruption lags in that condition, and it is possible that virtual interruptions may permit people greater temporal flexibility in managing their engagement with interruptions.

Systematic engineering tools for describing and improving medication administration processes at rural healthcare facilities

This study demonstrates a series of systematic methods for mapping medication administration processes and for elaborating violations of work standards at two rural hospitals. Thirty-four observational periods were conducted to capture the details of clinical activities, and hierarchical task analysis (HTA) was used to demonstrate the current medication administration process. Facility nurse managers in five units across the two facilities participated in focus group discussions to validate the observational data and to generate a reliable context-appropriate medication administration process. The potential errors or misconduct when passing the drugs were identified, such as unsafe storage and transportation of drugs from room to room. Those hazards would cause drug contamination, loss, or access by unauthorized individuals. Hospitals without 24-hour pharmacy coverage and other interruptions would hinder the medication administration process. Preparing drugs for more than one patient at a time would increase the risk of passing the drugs to the wrong patient. This study shows the use of observation and focus groups to describe and identify violations in the medication administration process. A clear road map for continuous clinical process improvement obtained from the current study could be used to help future health information technology implementation.

Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety

OBJECTIVE

This study tested multivariate models exploring unit-level predictors of medication administration (MA) accuracy.

BACKGROUND

During MA, nurses are both the last line of defense from medication-related errors and a potential perpetrator of error. Direct observation reveals safe practices and the accuracy of medication delivery.

METHODS

Using a direct-observation, cross-sectional design, data submitted by 124 adult patient care units for 15600 medication doses, from January 2009 to April 2010, were studied.

RESULTS

Distractions and interruptions were the most common safe practice deviation. Characteristics of patient care units and RN hours of care affected nurses' safe practices and MA accuracy. Safe practices predict and mediate MA accuracy. A 5% decrease in safe practice deviations would reduce MA errors by 46% without any change in RN hours of care.

CONCLUSION

Nurses' adherence to MA safe practices, combined with unit characteristics and staffing factors, has the potential to dramatically improve MA accuracy.

Situation Awareness and Interruption Handling During Medication Administration

Medication administration error remains a leading cause of preventable death. A gap exists in understanding attentional dynamics, such as nurse situation awareness (SA) while managing interruptions during medication administration. The aim was to describe SA during medication administration and interruption handling strategies. A cross-sectional, descriptive design was used. Cognitive task analysis (CTA) methods informed analysis of 230 interruptions. Themes were analyzed by SA level. The nature of the stimuli noticed emerged as a Level 1 theme, in contrast to themes of uncertainty, relevance, and expectations (Level 2 themes). Projected or anticipated interventions (Level 3 themes) reflected workload balance between team and patient foregrounds. The prevalence of cognitive time-sharing during the medication administration process was remarkable. Findings substantiated the importance of the concept of SA within nursing as well as the contribution of CTA in understanding the cognitive work of nursing during medication administration.

Evaluation of a configural vital signs display for intensive care unit nurses

OBJECTIVE

The objective was to evaluate a configural vital signs (CVS) display designed to support rapid detection and identification of physiological deterioration by graphically presenting patient vital signs data.

BACKGROUND

Current display technology in the intensive care unit (ICU) is not optimized for fast recognition and identification of physiological changes in patients. To support nurses more effectively, graphical or configural vital signs displays need to be developed and evaluated.

METHOD

A CVS display was developed based on findings from studies of the cognitive work of ICU nurses during patient monitoring. A total of 42 ICU nurses interpreted data presented either in a traditional, numerical format (n = 21) or on the CVS display (n = 21). Response time and accuracy in clinical data interpretation (i.e., identification of patient status) were assessed across four scenarios.

RESULTS

Data interpretation speed and accuracy improved significantly in the CVS display condition; for example, in one scenario nurses required only half of the time for data interpretation and showed up to 1.9 times higher accuracy in identifying the patient state compared to the numerical display condition.

CONCLUSION

Providing patient information in a configural display with readily visible trends and data variability can improve the speed and accuracy of data interpretation by ICU nurses.

APPLICATION

Although many studies, including this one, support the use of configural displays, the vast majority of ICU monitoring displays still present clinical data in numerical format. The introduction of configural displays in clinical monitoring has potential to improve patient safety.

Hospital paediatricians' workflow interruptions, performance, and care quality: a unit-based controlled intervention

OBJECTIVE

Frequent workflow interruptions jeopardise clinicians' efficiency and quality of clinical care. We sought to determine the effect of a documentation-assistant intervention. Our hypothesis was that the expected decrease of workflow interruptions enhances paediatricians' performance and simultaneously improves patients' perceived quality of care.

METHODS

This was a controlled intervention study with data collected before and after the intervention at a University Children's Hospital. For the intervention, a documentation assistant was assigned to an inpatient ward. The main outcome measures were workflow interruptions, paediatricians' performance, as well as patients' perceived quality of care. Workflow interruptions were assessed via standardised expert observations. Paediatricians' evaluated their performance in terms of productivity, quality, and efficiency. Additionally, standardised patients' reports on perceived quality of care were collected.

RESULTS

For paediatricians in the intervention ward, workflow interruptions decreased significantly from 5.2 to 3.1 disruption events per working hour (decrease in the control unit was from 3.8 to 3.1). Furthermore, paediatricians reported at follow-up significantly enhanced productivity, quality, and efficiency. Similarly, patients' ratings of care quality improved significantly over time. In multivariate analyses, we found substantial changes attributable to the intervention: for all three outcomes, we found a significant interaction effect of the intervention over study time.

CONCLUSIONS

The intervention streamlined paediatricians' workflow, improved day-to-day functioning of the ward, and enhanced organisational efficiency and delivery of paediatric care. Future studies should investigate potential influences between the reduction of workflow interruptions, paediatricians' perceived performance, and patient-related outcomes in quality and efficiency of paediatric care.

A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective

The purpose of this study was to understand the cognitive processes underlying nurses' decision to interrupt other nurses. The Institute of Medicine (2000) reported that interruptions are likely contributors to medical errors. Unfortunately, the research to date has been quite homogenous, focusing only on the healthcare provider being interrupted, ignoring the true complexities of interruptions. This study took a socio-technical approach being the first to examine interruptions from the viewpoint of the interrupting nurse. Over 15 h of observations and 10 open-ended interviews with expert nurses in a Neuroscience Surgical Intensive Care Unit were conducted. It was found that nurses conduct a quick cost-benefit assessment to determine the interruptibility of other nurses and whether an interruption is value-added vs. non-value added. To complete the assessment, nurses consider several conditional factors related to the interruptee, the interrupter, and the nature of the interruption content, and different potential consequences of the interruption.

Managing competing demands through task-switching and multitasking: a multi-setting observational study of 200 clinicians over 1000 hours

OBJECTIVE

To provide a detailed characterisation of clinicians' work management strategies.

DESIGN

1002.3 h of observational data were derived from three previous studies conducted in a teaching hospital in Sydney, Australia, among emergency department (ED) doctors (n=40), ward doctors (n=57) and ward nurses (n=104). The rates of task-switching (pausing a task to handle an incoming task) and multitasking (adding a task in parallel to an existing task) were compared in each group. Random intercepts logistic regression was used to determine factors significantly associated with clinicians' use of task-switching over multitasking and to quantify variation between individual clinicians.

RESULTS

Task-switching rates were higher among ED doctors (6.0 per hour) than ward staff (2.2 and 1.8 per hour for doctors and nurses, respectively) and vice versa for multitasking rates (9.2 vs 17.3 and 14.1 per hour). Clinicians' strategy use was significantly related to the nature and complexity of work and to the person they were working with. In some settings, time of day, day of the week or previous chosen strategy affected a clinician's strategy. Independent of these factors, there was significant variation between individual clinicians in their use of strategies in a given situation (ED doctors p=0.04, ward staff p=0.03).

CONCLUSIONS

Despite differences in factors associated with work management strategy use among ED doctors, ward doctors and ward nurses, clinicians in all settings appeared to prioritise certain types of tasks over others. Documentation was generally given low priority in all groups, while the arrival of direct care tasks tended to be treated with high priority. These findings suggest that considerations of safety may be implicit in task-switching and multitasking decisions. Although these strategies have been cast in a negative light, future research should consider their role in optimising competing quality and efficiency demands.

Turning over patient turnover: an ethnographic study of admissions, discharges, and transfers

The impact on nursing work of patient turnover (admissions, discharges, and transfers) became evident in an ethnographic study of turbulence. The patient turnover data were generated from extensive observations, 21 formal interviews, and a year of admission and discharge records on one medical and one surgical unit. Timing of turnover events on the two units differed, but on both units admissions typically interrupted workflow more than did discharges, clustered admissions were more disruptive than staggered admissions, and patient turnover during change of shift was more disruptive than during medication administration. Understanding the complexity of patient turnover will elucidate the work involved and improve the evidence base for nurse staffing, a key determinant of quality and safety of care.

Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital

Prostacyclins are a high-risk category of continuous intravenous infusions increasingly used in hospitals to treat advanced pulmonary arterial hypertension, a rare condition characterized by vasoconstriction and vascular proliferation of the pulmonary arteries. Prostacyclins are given in doses of nanograms per kilogram per minute and have a narrow therapeutic dosing range for each patient. Sudden increases or decreases in dose can be life threatening. Previous studies revealed errors in the administration of these high-risk infusions, which in some instances led to serious adverse events, including death. The literature was reviewed for safety measures in administration of high-risk intravenous medications and input was obtained from leading experts in pulmonary arterial hypertension to create a set of safety recommendations for infusion of prostacyclins.

Human Factors in Critical Care Medical Environments

The purpose of this chapter on human factors in critical care medical environments is to provide a systematic review of the human factors and ergonomics contributions that led to significant improvements in patient safety over the last five decades. The review will focus on issues that contributed to patient injury and fatalities and how human factors and ergonomics can improve performance of providers in critical care. Given the complexity of critical care delivery, a review needs to cover a wide range of subjects. In this review, I take a sociotechnical systems perspective on critical care and discuss the people, their technical and nontechnical skills, the importance of teamwork, technology, and ergonomics in this complex environment. After a description of the importance of a safety climate, the chapter will conclude with a summary on how human factors and ergonomics can improve quality in critical care delivery.

Interruptions in clinical nursing practice

AIMS AND OBJECTIVES

To report a descriptive study of interruptions in hospital nurses' work and discuss their consequences for nursing work.

BACKGROUND

Interruptions negatively affect procedures, work flow and patient safety. They disturb the emotional atmosphere, reflective processes and the interaction with patients. The constant rearranging of priorities forced by interruptions are a source of frustration to nurses and may lead to a feeling of being pressed for time that results in reduced job satisfaction and stress-related symptoms.

DESIGN

An ethnographic study.

METHODS

Observation of five nurse's work over three weeks in January 2007 and qualitative interviewing of two nurses.

RESULTS

Nurses were interrupted primarily by brief question-answer exchanges between nurse colleagues. Grouped by task, interruptions during medicine preparation in the ward's drug storage room were the most frequent, while the patients were responsible for fewer interruptions than was any other group. Nurses regarded some interruptions as unavoidable, others as avoidable, while the perception of other professional groups as the primary instigators of interruptions was not corroborated.

CONCLUSIONS

Interruptions confront nurses with a dilemma between being accessible to others and remaining focused in order to 'see the big picture'. Nurses' professional 'groundedness' seems to determine their ability to retain a state of equilibrium in a field of unnecessary interruptions and to prevent interruptions from occurring.

RELEVANCE TO CLINICAL PRACTICE

The study contributes new knowledge to the discussion of issues concerning organisation, management, training and clinical work, including nurse's ability to 'see the big picture'. It further seeks to clarify conditions for nursing that take into account professional standards and values as well as mutual understanding between colleagues.

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review

Background

Medication administration errors are frequent and lead to patient harm. Interruptions during medication administration have been implicated as a potential contributory factor.

Objective

To assess evidence of the effectiveness of interventions aimed at reducing interruptions during medication administration on interruption and medication administration error rates.

Methods

In September 2012 we searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Effective Practice and Organisation of Care Group reviews, Google and Google Scholar, and hand searched references of included articles. Intervention studies reporting quantitative data based on direct observations of at least one outcome (interruptions, or medication administration errors) were included.

Results

Ten studies, eight from North America and two from Europe, met the inclusion criteria. Five measured significant changes in interruption rates pre and post interventions. Four found a significant reduction and one an increase. Three studies measured changes in medication administration error rates and showed reductions, but all implemented multiple interventions beyond those targeted at reducing interruptions. No study used a controlled design pre and post. Definitions for key outcome indicators were reported in only four studies. Only one study reported κ scores for inter-rater reliability and none of the multi-ward studies accounted for clustering in their analyses.

Conclusions

There is weak evidence of the effectiveness of interventions to significantly reduce interruption rates and very limited evidence of their effectiveness to reduce medication administration errors. Policy makers should proceed with great caution in implementing such interventions until controlled trials confirm their value. Research is also required to better understand the complex relationship between interruptions and error to support intervention design.

Nature and impact of interruptions on clinical workflow of medical residents in the inpatient setting

BACKGROUND

Medical officers (trainees) in their first to third postgraduate years (PGY-1-3s) work in complex, busy environments, performing tasks that require concentration and application of learned skills. There are frequently competing demands, and being paged is among the most common.

OBJECTIVE

We quantified and described the effect of interruptions that paging created on the clinical workflow of PGY-1-3s during ward duties.

METHODS

This prospective study was conducted at 2 teaching hospitals in Sydney, Australia. Medical students were recruited as observers to log interruptions of PGY-1-3s' workflow arising from pages from other members of the hospital team.

RESULTS

Forty-two pairs consisting of a PGY-1-3 trainee and an observer were recruited, with 24 proceeding to data collection. Nursing was the most frequent source of pages (47%); other medical staff accounted for 16% of pages, allied health for 12%, and others for 24% (with pharmacy the most common). Pages commonly involved direct patient care (46%), followed by medication issues (21%). Tasks interrupted by pages encompassed direct patient care (37%), indirect patient care (15%), and documentation (12%). Only 27% of pages were assessed as appropriate and urgent, while 58% were considered appropriate but not urgent, and 16% were not appropriate. Only 38% of pages were judged to be clinically more important than the task they interrupted.

CONCLUSIONS

Pages frequently interrupted direct patient care activities for PGY-1-3 trainees, and a significant proportion of pages were identified as either not requiring immediate attention or not appropriate, resulting in potentially avoidable interruptions to clinical workflow. Alternate means of alerting trainees to nonurgent tasks may reduce interruptions and facilitate patient care.

Reducing interruptions during medication administration: the White Vest study

The well-established Institute of Medicine report entitled To Err is Human: Building a Safer Health System highlighted the importance of preventative errors in medicine, suggesting interruptions are a contributing factor. Patient safety organisations, such as The Joint Commission, acknowledge that interruptions contribute to preventable medical errors. The aim of this research is to examine the most frequently observed interruptions experienced by nurses administering medications and evaluate an intervention designed to reduce those interruptions. The primary intervention consisted of a White Vest worn during administration stating: ‘Please do not interrupt while passing medications’. A quasi-experimental design was employed. Nurses were observed for 2 weeks during routine administration of morning medications. The vest was then introduced and worn during administration for 2 weeks for post-intervention data collection. The hospital unit, date, time, duration, and description of the interruption were recorded. Data collection was conducted in four hospital units sequentially. A content analysis revealed the most frequently observed interruptions were comments/questions by hospital staff, phone calls, and seeking supplies. As hypothesised, the overall number of interruptions during medication administration (MA) declined after implementation of the intervention. This study illustrates implications and policy changes with regards to nursing practices and MA.

Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy

AIM

To explore the level of moral distress and potential associations between moral distress indices and (1) nurse-physician collaboration, (2) autonomy, (3) professional satisfaction, (4) intention to resign, and (5) workload among Italian intensive care unit nurses.

BACKGROUND

Poor nurse-physician collaboration and low autonomy may limit intensive care unit nurses' ability to act on their moral decisions.

METHODS

A cross-sectional correlational design with a sample of 566 Italian intensive care unit nurses.

RESULTS

The intensity of moral distress was 57.9 ± 15.6 (mean, standard deviation) (scale range: 0-84) and the frequency of occurrence was 28.4 ± 12.3 (scale range: 0-84). The mean score of the severity of moral distress was 88.0 ± 44 (scale range: 0-336). The severity of moral distress was associated with (1) nurse-physician collaboration and dissatisfaction on care decisions (r = -0.215, P < 0.001); and (2) intention to resign (r = 0.244, P < 0.0001). The frequency of occurrence of moral distress was associated with the intention of nurses to resign (r = -0. 209, P < 0.0001).

CONCLUSION

Moral distress seems to be associated with the intention to resign, whereas poor nurse-physician collaboration appears to be a pivotal factor accounting for nurses' moral distress.

IMPLICATIONS FOR NURSING MANAGEMENT

Enhancement of nurse-physician collaboration and nurses' participation in end-of-life decisions seems to be a managerial task that could lead to the alleviation of nurses' moral distress and their retention in the profession.

When nurses become the "second" victim

PURPOSE

Well-intentioned, conscientious nurses make medication errors. The subsequent feelings of guilt, remorse, and loss of personal and professional self-esteem these nurses experience are well documented. In this paper, we analyze the concept of "second victim" within the context of medication administration errors. We also examine factors that contribute to nurses becoming second victims after making an error.

PRACTICE IMPLICATIONS

Implications for nurses and nursing practice include nurses being given a greater degree of authority in designing the nursing work environment. Implications for nurses and nursing practice are presented.

CONCLUSION

Further study is needed to more fully understand this phenomenon and to discover appropriate support mechanisms and interventions to minimize the harm to nurses.

Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center

OBJECTIVES

In our Quebec (Canada) University Hospital Center, 68 medication carts have been implemented as part of a nationally funded project on drug distribution technologies. There are limited data published about the impact of medication carts in point-of-care units. Our main objective was to assess nursing staff's perception and satisfaction of medication carts on patient safety and ergonomics.

METHOD

Quantitative and qualitative cross-sectional study. Data were gathered from a printed questionnaire administered to nurses and an organized focus group composed of nurses and pharmacists.

RESULTS

A total of 195 nurses completed the questionnaire. Eighty percent of the nurses agreed that medication carts made health care staff's work easier and 64% agreed that it helped to reduce medication incidents/accidents. Only 27% and 43% agreed that carts' location reduces the risk of patients' interruptions and colleagues' interruptions, respectively. A total of 17 suggestions were extracted from the focus group (n = 7 nurses; n = 3 pharmacist) and will be implemented in the next year.

CONCLUSIONS

This descriptive study confirms the positive perception and satisfaction of nurses exposed to medication carts. However, interruptions are a major concern and source of dissatisfaction. The focus group has revealed many issues which will be improved.

Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis

BACKGROUND

Asynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer "pop-up" messages are understudied. Our objective was to create an asynchronous alert taxonomy and measure the impact of different alert types on practitioner workload.

METHODS

We quantified and categorized asynchronous alerts according to the information they conveyed and conducted a time-motion analysis to assess practitioner workload. We reviewed alert information transmitted to all 47 primary care practitioners (PCPs) at a large, tertiary care Veterans Affairs facility over 4 evenly spaced 28-day periods. An interdisciplinary team used content analysis to categorize alerts according to their conveyed information. We then created an alert taxonomy and used it to calculate the mean number of alerts of each type PCPs received each day. We conducted a time-motion study of 26 PCPs while they processed their alerts. We used these data to estimate the uninterrupted time practitioners spend processing alerts each day.

RESULTS

We extracted 295,792 asynchronously generated alerts and created a taxonomy of 33 alert types categorized under 6 major categories: Test Results, Referrals, Note-Based Communication, Order Status, Patient Status Changes, and Incomplete Task Reminders. PCPs received a mean of 56.4 alerts/day containing new information. Based on 749 observed alert processing episodes, practitioners spent an estimated average of 49 minutes/day processing their alerts.

CONCLUSIONS

PCPs receive a large number of EHR-based asynchronous alerts daily and spend significant time processing them. The utility of transmitting large quantities and varieties of alerts to PCPs warrants further investigation.

Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project

AIMS

To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions.

BACKGROUND

In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration.

METHODS

A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period.

RESULTS

A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption.

CONCLUSIONS

The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors.

IMPLICATIONS FOR NURSING MANAGEMENT

An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting.