Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy

Impact of implementing the aseptic compounding management system, Medcura, on internal error rates within an oncology pharmacy aseptic unit: a mixed methods evaluation

BACKGROUND

As cancer survivorship improves, pressure on oncology services to provide safe, timely treatments increases. Traditional manual compounding processes are error prone, putting patients at risk. Additionally, errors have a detrimental impact on service delivery and staff morale. Information technology is increasingly utilised to improve safety and service delivery of systemic anti-cancer therapy (SACT). The compounding process control system, Medcura, was developed to manage the end-to-end process and reduce transcription and calculation errors.

OBJECTIVES

To evaluate the impact of implementing Medcura on internal errors and staff perceptions of errors.

METHOD

An aseptic process control system, Medcura, was implemented in a busy pharmacy chemotherapy production unit. Internal error and severity data were collected and analysed for 14 months before and during implementation, and 24 months after implementation. In addition, one-to-one semi-structured interviews were carried out with pharmacy staff, pre- and post-implementation. Interviews were transcribed and thematically analysed.

RESULTS

Error rates decreased after implementation from 2.9% to 2.1%. The types of error detected also changed with a decrease in worksheet and labelling errors, and an increase in assembly errors. The severity of the errors, as a percentage of total errors made, also decreased after implementation. Staff were predominantly positive about Medcura; it reduced the number of errors, eased the preparation of worksheets and labels, reduced pressure and work-related stress, and improved job satisfaction.

CONCLUSIONS

Implementing Medcura has resulted in a reduction in both error rate and severity. Specifically, errors related to label and worksheet generation have seen the largest reduction. Staff have viewed these changes positively and report reduced levels of work-related stress. Further development and roll-out will improve patient safety and staff morale.

The hedonic overdrive model best explains high-fat diet-induced obesity in C57BL/6 mice

OBJECTIVE

High-fat diets cause obesity in male mice; however, the underlying mechanisms remain controversial. Here, three contrasting ideas were assessed: hedonic overdrive, reverse causality, and passive overconsumption models.

METHODS

A total of 12 groups of 20 individually housed 12-week-old C57BL/6 male mice were exposed to 12 high-fat diets with varying fat content from 40% to 80% (by calories), protein content from 5% to 30%, and carbohydrate content from 8.4% to 40%. Body weight and food intake were monitored for 30 days after 7 days at baseline on a standard low-fat diet.

RESULTS

After exposure to the diets, energy intake increased first, and body weight followed later. Intake then declined. The peak energy intake was dependent on both dietary protein and carbohydrate, but not the dietary fat and energy density, whereas the rate of decrease in intake was only related to dietary protein. On high-fat diets, the weight of food intake declined, but despite this average reduction of 14.4 g in food intake, they consumed, on average, 357 kJ more energy than at baseline.

CONCLUSIONS

The hedonic overdrive model fit the data best. The other two models were not supported.

Opportunities to strengthen resilience of health care workers regarding patient safety

BACKGROUND

The COVID-19 pandemic endangered the quality of health care and the safety of patients and health care workers (HCWs). This provided challenges for HCWs' resilience and for hospital management and probably increased risks for patient safety incidents (PSI). HCWs may also have experienced psychological consequences as second victims of PSI, but evidence on this is lacking. Therefore, we mapped HCWs' experiences with PSI during the second wave of COVID-19, the associations of these experiences with the hospital management of patient safety culture and HCWs' interests in receiving further training.

METHODS

We obtained data from 193 HCWs working at the COVID-related departments of one large hospital in eastern Slovakia via a questionnaire developed in direct collaboration with them. We measured PSI experiences as various HCWs' experiences with near miss and adverse events and the hospital management of patient safety culture using indicators such as risk of recurrence, open disclosure and second victim experiences. For analysis, we used logistic regression models adjusted for age and gender of the HCWs.

RESULTS

One-third of the hospital HCWs had experienced PSI; these were more likely to expect adverse events to recur (odds ratio, OR = 2.7-3.5). Regarding the hospital management of patient safety culture, the HCWs' experiencing openly disclosed PSI was associated with one negative outcome, i.e. conflicts among colleagues (OR = 2.8), and one positive outcome, i.e. patients' acceptance of their explanation and apologies (OR = 2.3). We found no associations for any other essential domains after disclosure. PSI experiences were strongly associated with psychological indicators of second victimhood, such as sadness, irritability, anxiety and depression (OR = 2.2-4.3), while providing support was not. The majority of the HCWs would like to participate in the suggested trainings (83.4%).

CONCLUSION

HCWs with PSI experiences reported poor hospital management of the patient safety culture, which might reflect they missed the opportunities to strengthen their resilience, especially during the COVID-19 pandemic.

Ward-level leadership quality and prospective low-back pain of eldercare workers: do resident handlings mediate the association?

OBJECTIVE

We investigated the extent to which ward-level leadership quality was associated with prospective low-back pain among eldercare workers, and how this association was mediated by observed resident handlings.

METHODS

530 Danish eldercare workers, employed in 121 wards, distributed across 20 nursing homes were evaluated. At baseline, leadership quality was measured using the Copenhagen Psychosocial Questionnaire, and resident handlings [handlings per shift, handlings not using assistive devices, handlings done alone, interruptions to handlings, impediments to handlings] were assessed using observations. Frequency and intensity of low-back pain was assessed monthly during the following year. All variables were averaged for each ward. We used ordinary least squares regressions to examine direct effects of leadership on low-back pain and indirect effects through handlings, using PROCESS-macro for SPSS.

RESULTS

After adjustments for low-back pain at baseline, type of ward, staff ratio (i.e., number of workers divided by number of residents) and proportion of devices not in place, leadership quality showed no effect on prospective low-back pain frequency (β = 0.01 [- 0.05:0.07]) and a small beneficial effect on pain intensity (β = - 0.02 [- 0.04:0.00]). Resident handlings did not mediate the association between leadership quality and frequency or intensity of low-back pain.

CONCLUSIONS

Good leadership quality was associated with a small decrease in prospective low-back pain intensity, but resident handlings did not seem to play a mediating role, although better ward-level leadership quality contributed to fewer workplace-observed resident handlings without assistance. Potentially, organizational factors, such as type of ward and staff ratio, may have a greater influence on handlings and low-back pain than leadership quality per se among eldercare workers.

Examining the Effect of Interruptions at Different Breakpoints and Frequencies Within a Task

OBJECTIVE

The purpose was to explore how event segmentation theory (EST) can be used to determine optimal moments for an interruption relying on hierarchical task analysis (HTA) to identify coarse and fine event boundaries.

BACKGROUND

Research on the effects of interruptions shows that they can be either disruptive or beneficial, depending on which aspects of an interruption are manipulated. Two important aspects that contribute to these conflicting results concern when and how often interruptions occur.

METHOD

Undergraduates completed a trip planning task divided into three subtasks. The within-subjects factor was interruption timing with three levels: none, coarse breakpoints, and fine breakpoints. The between-subjects factor was interruption frequency with two levels: one and three. The dependent measures included resumption lag, number of errors, mental workload, and frustration.

RESULTS

Participants took longer to resume the primary task and reported higher mental workload when interruptions occurred at fine breakpoints. The effect of interruptions at coarse breakpoints was similar to completing the task without interruption. Interruption frequency had no effect on performance; however, participants spent significantly longer attending to interruptions in the initial task, and within a task, the first and second interruptions were attended to significantly longer than the third interruption.

CONCLUSION

The disruptiveness of an interruption is tied to the point within the task hierarchy where it occurs.

APPLICATION

The performance cost associated with interruptions must be considered within the task structure. Interruptions occurring at coarse breakpoints may not be disruptive or have a negative effect on mental workload.

The Association Between Catheter Type and Dialysis Treatment: A Retrospective Data Analysis at Two U.S.-Based ICUs

Dialysis catheter type may be associated with differences in continuous renal replacement therapy (CRRT) treatment in the critically ill, with potential implications for patient outcomes and healthcare costs.

OBJECTIVES

To evaluate the association between the catheter type and multiple dialysis treatment outcomes among the critically ill.

DESIGN

Retrospective, observational study.

SETTING

Two U.S.-based ICUs.

PARTICIPANTS

Critically ill patients receiving CRRT between April 1, 2018, and July 1, 2020. A total of 1,037 CRRT sessions were analyzed.

MAIN OUTCOMES AND MEASURES

Circuit life, alarm interruption frequency (including a subset of vascular access [VA]-related alarms), termination type (elective vs nonelective), and blood flow rates. Pre- (n = 530) and post-catheter change (n = 507) periods were assessed, and the post-change period was further divided into intervals of pre-COVID (n = 167) and COVID contemporaneous (n = 340) to account for the pandemic's impact.

RESULTS

Compared with pre-change sessions, post-change sessions had 31% longer circuit life (95% CI, 1.14-1.49; p < 0.001), 3% higher blood flow rate (1.01-1.05; p < 0.01), and lower proportion of nonelective terminations (adjusted odds ratio [OR], 0.42 [0.28-0.62]; p < 0.001). There were fewer interruptions for all alarms (adjusted count ratio, 0.95 [0.87-1.05]; p = 0.31) and VA-related alarms (0.80 [0.66-0.96]; p = 0.014). The sessions during COVID period were statistically similar to pre-COVID sessions for all outcomes except a lower proportion of nonelective terminations (adjusted OR, 0.39 [0.22-0.70]; p < 0.01).

CONCLUSIONS

A change in catheter type was associated with longer CRRT sessions with fewer interruptions and unexpected terminations in a population of critical patients.

Evaluating the safety and efficiency of robotic dispensing systems

BACKGROUND

Although automated dispensing robots have been implemented for medication dispensing in Japan, their effect is yet to be fully investigated. In this study, we evaluated the effect of automated dispensing robots and collaborative work with pharmacy support staff on medication dispensing.

METHODS

A robotic dispensing system integrating the following three components was established: (1) automated dispensing robot (Drug Station®), which is operated by pharmacy support staff, (2) automated dispensing robot for powdered medicine (Mini DimeRo®), and (3) bar-coded medication dispensing support system with personal digital assistance (Hp-PORIMS®). Subsequently, we evaluated the incidences of dispensing errors and dispensing times before and after introducing the robotic dispensing system. Dispensing errors were classified into two categories, namely prevented dispensing errors and unprevented dispensing errors. The incidence of dispensing errors was calculated as follows: incidence of dispensing errors = total number of dispensing errors/total number of medication orders in each prescription.

RESULTS

After introducing the robotic dispensing system, the total incidence of prevented dispensing errors was significantly reduced (0.204% [324/158,548] to 0.044% [50/114,111], p < 0.001). The total incidence of unprevented dispensing errors was significantly reduced (0.015% [24/158,548] to 0.002% [2/114,111], p < 0.001). The number of cases of wrong strength and wrong drug, which can seriously impact a patient's health, reduced to almost zero. The median dispensing time of pharmacists per prescription was significantly reduced (from 60 to 23 s, p < 0.001).

CONCLUSIONS

The robotic dispensing system enabled the process of medication dispensing by pharmacist to be partially and safely shared with automated dispensing robots and pharmacy support staff. Therefore, clinical care for patients by pharmacists could be enhanced by ensuring quality and safety of medication.

Failure to demonstrate effects of interruptions on diagnostic reasoning: three experiments

BACKGROUND

Diagnostic error is a major source of patient suffering. Researchshows that physicians experience frequent interruptions while being engaged with patients and indicate that diagnostic accuracy may be impaired as a result. Since most studies in the field are observational, there is as yet no evidence suggesting a direct causal link between being interrupted and diagnostic error. Theexperiments reported in this article were intended to assess this hypothesis.

METHODS

Three experiments were conducted to test the hypothesis that interruptions hurt diagnostic reasoning and increase time on task. In the first experiment (N = 42), internal medicine residents, while diagnosing vignettes of actual clinical cases were interrupted halfway with a task unrelated to medicine, solving word-spotting puzzles and anagrams. In the second experiment (N = 78), the interruptions were medically relevant ones. In the third experiment (N = 30), we put additional time pressure on the participants. In all these experiments, a control group diagnosed the cases without interruption. Dependent variables were diagnostic accuracy and amount of time spent on the vignettes.

RESULTS

In none of the experiments interruptions were demonstrated to influence diagnostic accuracy. In Experiment 1: Mean of interrupted group was 0.88 (SD = 0.37) versus non- interrupted group 0.91 (SD = 0.32). In Experiment 2: Mean of interrupted group was 0.95 (SD = 0.32) versus non-interrupted group 0.94 (SD = 0.38). In Experiment 3: Mean of interrupted group was 0.42 (SD = 0.12) versus non-interrupted group 0.37 (SD = 0.08). Although interrupted residents in all experiments needed more time to complete the diagnostic task, only in Experiment 2, this effect was statistically significant.

CONCLUSIONS

These three experiments, taken together, failed to demonstrate negative effects of interruptions on diagnostic reasoning. Perhaps physicians who are interrupted may still have sufficient cognitive resources available to recover from it most of the time.

The Myth of Multitasking and What It Means for Future Pharmacists

Objective The primary purposes of this study were to determine the extent to which multitasking affects the speed and accuracy with which Doctor of Pharmacy students identify prescription errors and whether there is a relationship between students' self-perception of their multitasking ability and their actual ability.Methods One hundred twenty-one second-year pharmacy students enrolled in the required course Introduction to Dosage Forms spent one week in an experimental (multitasking) condition and one week in a control (undistracted) condition. Subjects were given 10 minutes to check 10 prescriptions and record any identified filling errors. A cellular phone was placed in each room. Subjects in the experimental (multitasking) condition answered a call from a researcher posing as a talkative customer during the prescription-checking task while subjects in the control condition were not interrupted by a cell phone call during the task. Subjects' completion times and accuracy were recorded.Results When subjects were multitasking, they took significantly longer to complete the prescription-checking task than when they were not multitasking. Furthermore, when subjects were multitasking, they scored significantly lower on the prescription-checking task than when they were not multitasking. Finally, students' self-perceptions of their multitasking abilities were not related to the speed with which they completed the prescription-checking task nor to their accuracy.Conclusion Multitasking negatively affects speed and accuracy of prescription verification in student pharmacists. Our procedure can be used as an in-class activity to demonstrate the limits of attention and to shape how future pharmacists practice.

Liability for Dispensing Errors in Hong Kong

The United Kingdom (UK) case R v Lee (2010) EWCA Crim 1404 resulted in a pharmacist being convicted for an inadvertent dispensing error and paved way for the decriminalisation of such errors by way of a due diligence defence enacted in 2018. In relation to Hong Kong (HK), what is its legal position for dispensing errors, and can it follow the decriminalising steps of UK? The primary objective of this paper is to explore whether and how HK can reach the normative position for a dispensing error legal regime: (1) I posit that the normative position for healthcare professional (HCP) liability for dispensing errors should prioritise the public interest of minimisation of future dispensing errors over the retribution of past wrongs; (2) I illustrate HK's current position for the liabilities of HCPs on dispensing errors, focusing analysis on the relatively controversial aspects of HK's criminal liability, referencing the landmark cases Hin Lin Yee v HKSAR (2009) 13 HKCFAR 142 and Kulemesin v HKSAR (2013) 16 HKCFAR 195 to assist my analysis of the requisite mental element for relevant statutory offences; (3) through comparison with UK's development post-R v Lee and application of Rule of Law principles, HK's current position is critiqued, coming to the conclusion that while there are compelling reasons for the decriminalisation of dispensing errors in HK, the prerequisite for this to happen is an overhaul of regulatory frameworks by significantly increasing levels of accountability.

Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage?

ABSTRACT

Interruptions are thought to be significantly associated with medication administration errors. Researchers have tried to reduce medication errors by decreasing or eliminating interruptions. In this article, we argue that interventions are often (perhaps unreflectively) based on one particular model of risk reduction-that of barriers placed between the source of risk and the object-to-be-protected. Well-intentioned interventions can lead to unanticipated effects because the assumptions created by the risk model are not critically examined. In this article, we review the barrier model and the assumptions it makes about risk and risk reduction/prevention, as well as the model's incompatibility with work in healthcare. We consider how these problems lead to interruptions interventions with unintended negative consequences. Then, we examine possible alternatives, viz organizing work for high reliability, preventing safety drift, and engineering resilience into the work activity. These all approach risks in different ways, and as such, propose interruptions interventions that are vastly different from interventions based on the barrier model. The purpose of this article is to encourage a different approach for designing interruptions interventions. Such reflection may help healthcare communities innovate beyond old, ineffective, and often counterproductive interventions to handle interruptions.

Multitasking in postanesthesia care unit following nurse interruptions, an analysis of the causes and consequences using classification tree: an observational prospective study

BACKGROUND

Postanesthesia Care Unit (PACU) is an environment associated with an important workload which is susceptible to lead to task interruption (TI), leading to task-switching or concurrent multitasking. The objective of the study was to determine the predictors of the reaction of the nurses facing TI and assess those who lead to an alteration of the initial task.

METHODS

We conducted a prospective observational study into the PACU of a university hospital during February 2017. Among 18 nurses, a selected one was observed each day, documenting for each TI the reaction of the nurse (task switching or concurrent multitasking), and the characteristics associated with the TI. We performed classification tree analyses using C5.0 algorithm in order to select the main predictors of the type of multitasking performed and the alteration of the initial task.

RESULTS

We observed 1119 TI during 132 hours (8.5 TI/hour). The main reaction was concurrent multitasking (805 TI, 72%). The short duration of the task interruption (one minute or less) was the most important predictor leading to concurrent multitasking. Other predictors of response to TI were the identity of the task interrupter and the number of nurses present. Regarding the consequences of the task switching, long interruption (more than five minutes) was the most important predictor of the alteration of the initial task.

CONCLUSIONS

By analysing the predictors of the type of multitasking in front of TI, we propose a novel approach to understanding TI, offering new perspective for prevention strategies.

Reduction of phone interruptions post implementation of a central call center in community pharmacies of an academic health system

PURPOSE

A pharmacy services call center (PSCC) was implemented to centralize pharmacy phone calls and reduce interruptions of dispensing activities in 7 community pharmacies of an academic health center. An evaluation was conducted to define, quantify, and compare the numbers and types of phone interruptions before and 3 months after PSCC implementation.

METHODS

Through structured, direct observation of pharmacy staff, the numbers and types of "breaks in task" (BIT) due to phone interruptions and other distractions were identified. A standardized data collection tool formatted on tablet computers was used by trained observers to document BIT for 3-hour time blocks on 5 consecutive business days (2 days of pharmacist observation and 3 days of technician observation, for a total of 10 observation days per pharmacy).

RESULTS

Over 5,000 prescriptions were processed during 414 hours of observation (13.3 prescriptions per observation hour). Overall, BIT due to phone interruptions totaled 2.2 BIT per observation hour, with those interruptions reduced by 46.4% overall after PSCC implementation (by 30.0% in 4 small pharmacies and by 57.5% in 3 large pharmacies). Technicians were more likely than pharmacists to be interrupted by phone vs nonphone BIT (eg, distraction by another technician, pharmacist, or patient). Comparison of phone vs nonphone BIT suggested an overall 46.0% reduction in phone BIT in all pharmacies (reductions of 42.4% and 45.0% in large and small pharmacies, respectively).

CONCLUSION

PSCC implementation noticeably decreased the amount of phone interruptions and distractions for employees.

Nature of dispensing errors in selected hospitals providing free healthcare: a multi-center study in Sri Lanka

Background

Dispensing errors, known to result in significant patient harm, are preventable if their nature is known and recognized. However, there is a scarcity of such data on dispensing errors particularly in resource poor settings, where healthcare is provided free-of-charge. Therefore, the purpose of this study was to determine the types, and prevalence of dispensing errors in a selected group of hospitals in Sri Lanka.

Methods

A prospective, cross sectional, multi-center study on dispensing errors was conducted, in a single tertiary care, and two secondary care hospitals, in a cohort of 420 patients attending medical, surgical, diabetic and pediatric clinics. The patients were selected according to the population size, through consecutive sampling. The prescription audit was conducted in terms of dispensing errors which were categorized as i) content, ii) labelling, iii) documentation, iv) concomitant, and v) other errors based on in-house developed definitions.

Results

A total of 420 prescriptions (1849 medicines) were analyzed (Hospital-I, 248 prescriptions-1010 medicines; Hospital-II, 84 prescriptions-400 medicines; Hospital-III, 88 prescriptions-439 medicines), and a cumulative total of 16,689 dispensing errors (at least one dispensing error in a prescription) were detected. Labelling errors were the most frequent dispensing error (63.1%; N = 10,523; Mostly missing information on the dispensing label), followed by concomitant prescribing and dispensing errors (20.5%; N = 3425; Missing prescribing information overlooked by the pharmacist), documentation errors (10.6%; N = 1772 Missing identification of pharmacist on dispensing label), clinically significant medication interactions overlooked by pharmacists (0.5%; N = 82), content errors (4.9%; N = 812; Discrepancies between medication dispensed and prescription order), medications dispensed in unsuitable packaging (0.4%; N = 74), and lastly medication dispensed to the wrong patient (0.01%; N = 1).

Conclusions

Dispensing errors are frequent in Sri Lankan hospitals which operate with limited resources and provide free healthcare to all citizenry. Over one half of the errors were labeling errors with minimal content errors. Awareness on common types of dispensing errors and emphasis on detecting them could improve medication safety in Sri Lankan hospitals.

Distractions During Patient Handoff: The Application-Based Messaging Volume on General Surgery Interns

OBJECTIVE

Mobile phone-based paging systems have become increasingly common for communication within hospitals. Surgical interns receive the most pages, and our aim is to objectively quantify and evaluate this burden to allow for targeted improvement.

DESIGN

We performed a retrospective review of our institutions mobile phone-based paging system data (Halo Health, Cincinnati, OH) from July 2019 to September 2019.

SETTING

Carolinas Medical Center, Charlotte, NC, USA.

PARTICIPANTS

Seven general surgery postgraduate year (PGY) 1 residents.

RESULTS

Forty-five thousand eight hundred and one messages met inclusion criteria, with 27,397 messages received and 18,404 sent. PGY 1 residents each received an average of 48 ± 41 messages per shift, with 8 ± 17 messages per day while off-duty. Night shifts averaged more messages than day shifts (80 ± 39 vs 38 ± 32, p < 0.0001), and had more shifts with high message volume (30% vs 11%, p = 0.0005). Evaluating the total number of messages received per minute of the day, the largest number of high-volume message intervals (21) occurred during patient handoff (1700-1900 hours). Most messages were sent by nursing staff (55.8%), followed by medical providers (38.2%).

CONCLUSIONS

PGY 1 residents receive a large number of pages using a messaging application, with many occurring at critical times. Residents received a higher volume of pages on night shifts, during patient handoff, and while off-duty. Since most pages are from nursing staff, targeted education and preventative actions may help decrease the volume of pages during these critical times.

Batch Reading and Interrupted Interpretation of Digital Screening Mammograms Without and With Tomosynthesis

OBJECTIVE

To compare batch reading and interrupted interpretation for modern screening mammography.

METHODS

We retrospectively reviewed digital mammograms without and with tomosynthesis that were originally interpreted with batch reading or interrupted interpretation between January 2015 and June 2017. The following performance metrics were compared: recall rate (per 100 examinations), cancer detection rate (per 1,000 examinations), and positive predictive values for recall and biopsy.

RESULTS

In all, 9,832 digital mammograms were batch read, yielding a recall rate of 9.98%, cancer detection rate of 4.27, and positive predictive values for recall and biopsy of 4.40% and 35.5%, respectively. There were 49,496 digital mammograms that were read with interrupted interpretation, yielding a recall rate of 11.3%, cancer detection rate of 4.44, and positive predictive values for recall and biopsy of 3.92% and 30.1%, respectively. Of the digital mammograms with tomosynthesis, 7,075 were batch read, yielding a recall rate of 6.98%, cancer detection rate of 5.37, and positive predictive values for recall and biopsy of 7.69% and 38.0%, respectively. Of the digital mammograms with tomosynthesis, 24,380 were read with interrupted interpretation, yielding a recall rate of 8.30%, cancer detection rate of 5.41, and positive predictive values for recall and biopsy of 6.52% and 33.3%, respectively. For both digital mammograms without and with tomosynthesis, recall rates improved with batch reading compared with interrupted interpretation (P < .001), but no significant differences were seen for other metrics.

DISCUSSION

Batch reading digital mammograms without and with tomosynthesis improves recall rates while maintaining cancer detection rates and positive predictive values compared with interrupted interpretation.

Effect of a central call center on employee perceptions of safety culture within community pharmacies in an academic health system

PURPOSE

This study evaluated employee perceptions of safety culture in 9 health-system-owned community pharmacies using a safety culture survey before and after implementation of a Pharmacy Services Call Center (PSCC) designed to reduce distractions through reduction of phone volume related to refills and prescription readiness.

METHODS

The Agency for Healthcare Research and Quality (AHRQ) Community Pharmacy Survey on Patient Safety Culture (CPSPSC) was used to collect employee safety culture perceptions pre-post PSCC implementation. A percent positive score (PPS) was calculated for each of 11 CPSPSC composite questions and for 1 overall rating of patient safety question based on AHRQ-suggested analytic procedures. Pre-post PSCC implementation, PPSs were compared using a chi-square test.

RESULTS

Overall, the lowest composite PPS (Staffing, Work Pressure, and Pace) and the highest composite PPS (Patient Counseling) ranked the same in both survey periods. Of the nine PSCC pharmacies, statistically significant (p < 0.05) PPS improvements occurred in 4 composites including Teamwork (11.9%), Communication About Mistakes (18%), Staff Training and Skills (20.6%), and Staffing, Work Pressure, and Pace (11.8%). PSCC pharmacies also reported a 9.3% (NS) improvement in overall rating of pharmacy patient safety post PSCC implementation. Separate analysis of pharmacist responses was consistent with pharmacy level results, but technician results differed slightly in overall rating of safety perceptions.

CONCLUSION

Presence of the PSCC appeared to increase pharmacy employees' perceptions of safety culture in the community pharmacies, an integral part of overall patient safety.

Is it time to rethink how we page physicians? Understanding paging patterns in a tertiary care hospital

Background

Frequent pages can disrupt workflow, interrupt patient care, and may contribute to physician burnout. We hypothesized that paging volumes followed consistent temporal trends, regardless of the medical or surgical service, reflecting systems based issues present in our hospitals.

Methods

A retrospective review of the hospital paging systems for 4 services at The Ottawa Hospital was performed. Resident paging data from April 1 to July 31, 2018 were collected for services with a single primary pager number including orthopaedic surgery, general surgery, neurology, and neurosurgery. Trends in paging volume during the 4-month period were examined. Variables examined included the location of origin of the page (emergency room vs. inpatient unit), and day/time of the page.

Results

During the study period, 25,797 pages were received by the 4 services, averaging 211 (± Standard Deviation (SD) 12) pages per day. 19,371 (75%) pages were from in-patient hospital units, while 6426 (24%) were pages from the emergency room. The median interval between pages across all specialties was 22:30 min. Emergency room pages peaked between 16:30 and 20:00, while in-patient units peaked between 17:30 and 18:30.

Conclusions

Each service experienced frequent paging with similar patterns of marked increases at specific times. This study identifies areas for future study about what the factors are that contribute to the paging patterns observed.

Assessment of perceived workload in academic health center community pharmacies before and after implementation of a central call center

PURPOSE

Results of a study to determine whether reducing pharmacy phone call workload through implementation of a pharmacy services call center (PSCC) led to decreased employee workload, improved efficiency, and increased pharmacist availability for patient care are reported.

METHODS

A pre-post study was conducted using the NASA Task Load Index (NASA-TLX) instrument. Pharmacists, pharmacy technicians at 7 academic health center community pharmacies, and PSCC staff provided NASA-TLX data over 5 days during 3 data collection periods before and after PSCC implementation. Perceived workload was measured as an overall workload score (OWS) and mean scores for 6 NASA-TLX workload dimensions (mental demand, physical demand, temporal demand, performance, effort, and frustration).

RESULTS

Relative to pre-PSCC values, mean postimplementation OWS scores significantly decreased in all 7 pharmacies (from 33.3 to 29.1 overall, p < 0.001) but especially in small pharmacies (from 31.7 to 27.6, p < 0.001). Scores for the physical demand and frustration dimensions were low in both the PSCC and in the 7 pharmacies, while scores for the performance dimension remained high (range, 6.8-8.3). In general, scores for all other measured NASA-TLX dimensions decreased after PSCC implementation, more so at smaller pharmacies. The PSCC staff mean OWS score increased over time (from 26.8 to 28.6, p < 0.0001) but remained near the overall pharmacy average of 29.1.

CONCLUSION

Use of the NASA TLX allowed for a direct subjective measurement of workload as perceived by pharmacy and PSCC employees before and after PSCC implementation. Long-term effects of the PSCC on workload should be assessed.

Visualising clinical work in the emergency department: Understanding interleaved patient management

We present a unique data visualisation approach, called workflow time charts, to illustrate the sequential and multi-dimensional nature of work in emergency departments. Using 40 h of data from direct observations of emergency physicians, we applied the charts to visualise patient-stratified physicians' work as a continuous temporal process, including distinguishing tasks of different types and representing external prompts (similar to interruptions) and multitasking performance. The charts showed frequent changes in the nature of observed activities, with interleaved multitasking a constant feature and external prompts often clustered in time. Evidence of seniority-related differences in work were apparent with consultants switching between more concurrent patients and receiving more frequent clinical prompts than junior physicians, illustrating their overseeing and advice-giving role. The ubiquity of interleaved multitasking suggests a need to focus on developing individual strategies to support frequent cognitive switching. Work that appears fragmented at physician level may form part of a flexible and robust system, rather than an error-prone set of isolated individual behaviours.

Interruptions and Delivery of Care in the Intensive Care Unit

OBJECTIVE

This study samples interruption frequency in intensive care unit (ICU) settings to assess the relationship between interruptions and common patient hazards.

BACKGROUND

Task interruptions are accident contributors in numerous industries. Recently, studies on health care interruptions and their impact on patient hazards have received attention.

METHOD

Seven ICUs in four hospitals participated in a 24-month study. Experienced ICU nurses directly observed nursing tasks, interruptions, and patient hazards (delays in care, breaks in device task protocols, and patient safety hazards).

RESULTS

During 1,148 hours of observation, 175 nurses performed 74,733 nursing tasks. Interruptions occurred at a rate of 4.95 per hour, and 8.4% of tasks were interrupted. Interruptions originated mostly from humans (65.9%), alarms (24.1%), and others (10%). A total of 774 patient hazards were observed, with a hazard occurring on average every 89 minutes. Relative to noninterrupted tasks, device alarm interrupted nonstructured tasks were associated with increased rates of delays in care and safety hazards (rate ratio [RR] = 3.19). In contrast, rate of delays in care and safety hazards did not increase during human interrupted tasks (RR = 1.13). Rates of protocol nonadherence varied by device type and were highest during artificial airway, medication administration, chest tube, and supplemental oxygen management.

CONCLUSION

Interruptions in the ICU are frequent and contribute to patient hazards, especially when caused by device alarms during nonstructured tasks. Nonadherence to protocols is common and contributed to patient hazards.

APPLICATION

The findings suggest a need for improvement in task and device design to reduce patient hazards.

Human factors awareness and recognition during multidisciplinary team meetings

Multidisciplinary team (MDT) meetings are widely used throughout medicine and dentistry, bringing together expertise and different opinions across many disciplines to benefit patient care. Depending on the cancer site and specialties involved, some MDTs can last for several hours, especially if there are many complex patients to discuss. However, concentration and attention can vary and distraction is almost inevitable with separate conversations between MDT members and the ever-increasing use of smartphones. The role of human factors (HF) in contributing to error is well known in high-risk activities including medicine and surgery. Surprisingly, while there is increasing awareness of their importance by medical and dental professionals to enhance patient safety, to our knowledge nothing to date has been published about the possible effect and role of HF at MDTs. Here we provide a brief HF overview and focus on the factors at an MDT that could lead to distraction, providing suggestions (including some from aviation) for possible ways to enhance and improve discussion during these often-long meetings. It is hoped that this paper will generate some thought and discussion around the current "normal" MDT practice in head and neck and other specialties and challenge colleagues to embrace HF and safety principles in a just and learning culture.

When a child dies of heatstroke after a parent or caretaker unknowingly leaves the child in a car: How does it happen and is it a crime?

It is commonly reported that in the course of a drive, a parent or caretaker loses awareness of the presence of a child in the back seat of the car. Upon arriving at the destination, the driver exits the car and unknowingly leaves the child in the car. This incomprehensible lapse of memory exposes forgotten children to hazards, including death from heatstroke. More than 400 children in the past 20 years have suffered from heatstroke after being unknowingly forgotten in cars. How can loving and attentive parents, with no evidence of substance abuse or an organic brain disorder, have a catastrophic lapse of memory that places a child's welfare in jeopardy? This article addresses this question at multiple levels of analysis. First, it is concluded that the loss of awareness of a child in a car is a failure of a type of memory referred to as prospective memory (PM), that is, failure to remember to execute a plan in the future. Second, factors that increase the likelihood that PM will fail are identified. Third, research on the neurobiology of PM and PM-related memory failures are reviewed, including a discussion of how competition between brain structures contributes to a failure of PM. Finally, the issue of whether a failure of PM that results in harm to a child qualifies as a criminal offence is discussed. Overall, this neuropsychological perspective on how catastrophic memory errors occur should be of value to the scientific community, the public and law-enforcement agencies.

Student observations of medication error reporting practices in community pharmacy settings

BACKGROUND

Medication safety practices and methods for reporting errors in community pharmacies are relatively unknown.

OBJECTIVE

(s): The primary objective of this study was to describe student-reported data on medication safety and error reporting practices in community pharmacies, and secondarily describe student learning from this assignment.

METHODS

Second professional year pharmacy students enrolled at Purdue University College of Pharmacy in the United States observed and recorded medication safety and error reporting practices as part of an experiential assignment. Data were collected from 170 unique pharmacy settings between the years 2016-2018 and analyzed using descriptive statistics and a paired t-test to assess student learning.

RESULTS

51% of students reported documentation of 1-10 errors or near misses annually, with an additional 30% reporting 11-30. Near misses were only reported 26% of the time. Errors were most commonly reported to a pharmacy-specific reporting system (84%) and the Institute for Safe Medication Practices National Medication Errors Reporting Program (84%). The most frequently reported error types included wrong directions (34%), wrong drug (14%), wrong strength (13%), and wrong patient (12%). Pharmacists were observed to be interrupted approximately 19 times every hour. Anonymous error reporting was typically not allowed to the pharmacy's preferred error reporting system (71%). A policy requiring that the prescriber is contacted about errors was observed at 77% of the sites. The most common consequences of committing an error were education/training (72%) or progressive discipline (41%). Students reported a statistically significant increase in understanding of medication safety practices and methods for reporting errors in community pharmacies. (p < 0.01).

CONCLUSION

This data supplements existing literature on medication safety practices and error reporting in community pharmacy settings, as well as highlights knowledge gaps outside the scope of this study.

The Impact of Phone Interruptions on the Quality of Simulated Medication Order Validation Using Eye Tracking: A Pilot Study

INTRODUCTION

Order validation is an important component of pharmacy services, where pharmacists review orders with a focus on error prevention. Interruptions are frequent and may contribute to a reduction in error detection, thus potential medication errors. However, studying such errors in practice is difficult. Simulation has potential to study these events.

METHODS

This was a pilot, simulation study. The primary objective was to determine the rate of medication error detection and the effect of interruptions on error detection during simulated validation. Secondary objectives included determining time to complete each prescription page. The scenario consisted of validating three handwritten medication order pages containing 12 orders and 17 errors, interrupted by three phone calls timed during one order for each page. Participants were categorized in groups: seniors and juniors (including residents). Simulation sessions were videotaped and eye tracking was used to assist in analysis.

RESULTS

Eight senior and five junior pharmacists were included in the analysis. There was a significant association between interruption and error detection (odds ratio = 0.149, 95% confidence interval = 0.042-0.525, P = 0.005). This association did not vary significantly between groups (P = 0.832). Juniors took more time to validate the first page (10 minutes 56 seconds vs. 6 minutes 42 seconds) but detected more errors (95% vs. 69%). However, all major errors were detected by all participants.

CONCLUSIONS

We observed an association between phone interruptions and a decrease in error detection during simulated validation. Simulation provides an opportunity to study order validation by pharmacists and may be a valuable teaching tool for pharmacists and pharmacy residents learning order validation.

Accuracy Screening for ST Elevation Myocardial Infarction in a Task-switching Simulation

INTRODUCTION

Interruptions in the emergency department (ED) are associated with clinical errors, yet are important when providing care to multiple patients. Screening triage electrocardiograms (ECG) for ST-segment elevation myocardial infarction (STEMI) represent a critical interrupting task that emergency physicians (EP) frequently encounter. To address interruptions such as ECG interpretation, many EPs engage in task switching, pausing their primary task to address an interrupting task. The impact of task switching on clinical errors in interpreting screening ECGs for STEMI remains unknown.

METHODS

Resident and attending EPs were invited to participate in a crossover simulation trial. Physicians first completed a task-switching simulation in which they viewed patient presentations interrupted by clinical tasks, including screening ECGs requiring immediate interpretation before resuming the patient presentation. Participants then completed an uninterrupted simulation in which patient presentations and clinical tasks were completed sequentially without interruption. The primary outcome was accuracy of ECG interpretation for STEMI during task switching and uninterrupted simulations.

RESULTS

Thirty-five participants completed the study. We found no significant difference in accuracy of ECG interpretation for STEMI (task switching 0.89, uninterrupted 0.91, paired t-test p=0.21). Attending physician status (odds ratio [OR] [2.56], confidence interval [CI] [1.66-3.94], p<0.01) and inferior STEMI (OR [0.08], CI [0.04-0.14], p<0.01) were associated with increased and decreased odds of correct interpretation, respectively. Low self-reported confidence in interpretation was associated with decreased odds of correct interpretation in the task-switching simulation, but not in the uninterrupted simulation (interaction p=0.02).

CONCLUSION

In our simulation, task switching was not associated with overall accuracy of ECG interpretation for STEMI. However, odds of correct interpretation decreased with inferior STEMI ECGs and when participants self-reported low confidence when interrupted. Our study highlights opportunities to improve through focused ECG training, as well as self-identification of "high-risk" screening ECGs prone to error during interrupted clinical workflow.

Interruptions in community pharmacies: Frequency, sources, and mitigation strategies

BACKGROUND

Interruptions constitute a key part of the communication strategy for healthcare providers, including community pharmacy personnel. Previous research in other healthcare environments has shown that interruptions are very common and may present as patient safety hazards. One 1999 study, conducted in community pharmacy settings, found that interruptions were prevalent and associated with dispensing errors. In the last 20 years, pharmacies have expanded patient services and implemented new technology. Yet, it is unknown how these changes have affected interruption sources and frequency.

OBJECTIVE

The objective was to characterize the frequency and sources of pharmacist task interruptions that occur in community pharmacies.

METHODS

A cross-sectional qualitative study design was used to evaluate the frequency and sources of pharmacist task interruptions in Wisconsin community pharmacies. The participants included 9 pharmacists and 9 technicians working in 2 independently-owned, 2 mass merchandise, and 2 hospital/clinical-affiliated pharmacies.

RESULTS

Interruption rates ranged from 3 to 7 per hour across the 6 pharmacies. Sources of interruptions included: patients, technicians, self-initiated interruptions, technology used in the pharmacy, and a second pharmacist.

CONCLUSIONS

Interruptions are common in community pharmacies and the causes are multifactorial. Prudent management of interruptions in these work environments may involve improved technician training and better designs of pharmacy technology.

Systematic review and meta-analysis of community pharmacy error rates in the USA: 1993-2015

Importance

While much is known about hospital pharmacy error rates in the USA, comparatively little is known about community pharmacy dispensing error rates.

Objective

The aim of this study was to determine the rate of community pharmacy dispensing errors in the USA.

Methods

English language, peer-reviewed observational and interventional studies that reported community pharmacy dispensing error rates in the USA from January 1993 to December 2015 were identified in 10 bibliographic databases and topic-relevant grey literature. Studies with a denominator reflecting the total number of prescriptions in the sample were necessary for inclusion in the meta-analysis. A random effects meta-analysis was conducted to estimate an aggregate community pharmacy dispensing error rate. Heterogeneity was assessed using the I² statistic prior to analysis.

Results

The search yielded a total of 8490 records, of which 11 articles were included in the systematic review. Two articles did not have adequate data components to be included in the meta-analysis. Dispensing error rates ranged from 0.00003% (43/1 420 091) to 55% (55/100). The meta-analysis included 1 461 128 prescriptions. The overall community pharmacy dispensing error rate was estimated to be 0.015 (95% CI 0.014 to 0.018); however, significant heterogeneity was observed across studies (I²=99.6). Stratification by study error identification methodology was found to have a significant impact on dispensing error rate (p<0.001).

Conclusion and relevance

There are few published articles that describe community pharmacy dispensing error rates in the USA. Thus, there is limited information about the current rate of community pharmacy dispensing errors. A robust investigation is needed to assess dispensing error rates in the USA to assess the nature and magnitude of the problem and establish prevention strategies.

A text mining analysis of medication quality related event reports from community pharmacies

BACKGROUND

Medication errors are estimated to cost $42 billion in annual global treatment costs. Pharmacy-based Patient Safety Organizations (PSO) are tasked with collecting and analyzing incidents, near misses, and unsafe condition reports as one way of engaging pharmacies in quality improvement efforts. Collectively, these reports are referred to as quality related events (QREs). Large-scale analysis of typed narratives from QRE reports across organizations has been a missing component of quality improvement programs.

OBJECTIVE

To identify topics within the components of a proposed medication safety event framework contained in the free-text narrative of QRE reports.

METHODS

A retrospective, observational analysis of data from a PSOs voluntary reporting system, from January 1, 2011 to December 31, 2014. The dataset contained structured and unstructured data elements. A structural topic model extracted themes from the free-text narrative component of the report. These topics were assigned a human label and mapped onto constructs of the medication safety event framework.

RESULTS

A total of 531,555 QREs were analyzed from 1660 pharmacies. 90.6% were near miss and unsafe condition reports. There were 40 topics generated. There were 29 topics identified as QRE types, 3 were identified as contributing factors, and 5 were related to signals/alerts that an incident or near miss had occurred. One topic each was identified as a recovery step and a quality improvement strategy. One topic was not assigned a human label. Examples of topics labeled included incorrect tapering directions, needing to double-check work, and attention-related contributing factor.

CONCLUSIONS

The free-text narrative provided novel information compared to the structured fields of the reports. Topics were mapped onto a proposed medication safety event framework to advance knowledge of medication QREs and identify ways to improve medication safety in community pharmacy. Future work may focus on communicating these topics to the pharmacies to improve medication safety efforts.

Minimizing the impact of interruptions in a pediatric retail pharmacy

Researchers identified two needs of the in-hospital pediatric retail pharmacy. First was the reduction of the risk and frequency of errors. Second was the need to improve the efficiency of primary pharmacy tasks. Interruptions were identified as the primary issue. The team performed an extensive literature review and conducted interviews and observations to assess the pharmacy work system, work flow, and the impact of interruptions. A human factors analysis was done to accurately represent the pharmacy work system from data collection, and derive recommendations to improve efficiency and accuracy. Some of the recommendations were rapidly implemented into the pharmacy work system, including increased staffing during periods of high work demand, changes to counter spacing, and design changes to bags intended to contain refrigerated components. The research team conducted follow-up observations and collected survey data from pharmacy staff to determine the impact of the implemented interventions and identify key improvements.

Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital

Aim

To determine the quality of best possible medication history (BPMH) taking activities undertaken by pharmacists. To identify factors which impact upon erroneous documentation. To assess risks associated with erroneous documentation of BPMH by pharmacists.

Method

A clinical pharmacist randomly selected patients across a tertiary referral, metropolitan hospital over an 9-day period and documented comparator medication histories (CMHs) using a structured interview. BPMH documented by pharmacists as part of routine care and CMH were compared, and erroneous documentation was classified according to previous definitions in the literature. Erroneous documentation was risk stratified.

Results

99 BPMH and CMH were compared. There were 14 medication omissions which occurred across 10 patients and 14 discrepancies across 12 patients. There was no association identified between erroneous documentation and pharmacist seniority/experience (p=0.25), where BPMH taken (p=0.7), day of week BPMH documented (p=0.45) or time since admission to when BPMH was documented (p=1). Patient age did not impact erroneous documentation rates (p=0.22). There was an association between the number of sources used to confirm a medication history and erroneous documentation incidence (p=0.035). The number of medications increased the rate of documentation error. While 85.19% (n=115) of erroneous documentation were deemed unlikely to cause patient discomfort or clinical deterioration, 1.48% (n=2) had the potential to result in severe discomfort or clinical deterioration.

Conclusion

Six out of seven BPMH documented by pharmacists as part of usual clinical practice are accurate. Major influences on accuracy include the number of medications and sources used. There is a low possibility that erroneous documentation by pharmacists will cause harm.

Community health integration through pharmacy process and ergonomics redesign (CHIPPER)

As the expansion and utilisation of community pharmacy systems increases, so does the risk for an adverse drug event to occur. In attempts to mitigate this risk, many community pharmacies implement health information technology (IT); however, there are challenges in integrating the wider systems components necessary for a successful implementation with minimal unintended consequences. The purpose of this paper is to introduce a Community Health Integration through Pharmacy Process and Ergonomics Redesign (CHIPPER) framework, which explores the multiple angles of health IT integration to support medication delivery processes in community pharmacy systems. Specifically, CHIPPER identifies the information flows that occur between different parts of the system (initiation, upstream, midstream and downstream) with varying end-users and tasks related to medication delivery processes. In addition to the justification and presentation of the CHIPPER model, this paper reviews several broad applications for CHIPPER and presents two example studies that demonstrate the CHIPPER framework. Practitioner Summary: Most medication delivery in the US occurs through outpatient-based community pharmacy practice. Community pharmacies are challenged by inconsistent and incomplete information flow and technology integration between providers, pharmacy practitioners and patients. This paper presents a framework for improved healthcare systems engineering analysis of pharmacy practice, with case study examples.

Are sound abatement measures necessary in the cytology reading room? A study of auditory distraction

OBJECTIVE

Listening to music and other auditory material during microscopy work is common practice among cytologists. While many cytologists would claim several benefits of such activity, research in other fields suggests that it might adversely affect diagnostic performance. Using a cross-modal distraction paradigm, the aim of the present study was to investigate the effect of auditory stimulation on the visual interpretation of cell images.

METHODS

Following initial training, 34 participants undertook cell interpretation tests under four auditory conditions (liked music, disliked music, speech and silence) in a counterbalanced repeated-measures study. Error rate, area under the receiver operating characteristic curve, criterion and response time were measured for each condition.

RESULTS

There was no significant effect of auditory stimulation on the accuracy or speed with which cell images were interpreted, mirroring the results of a previous visual distraction study.

CONCLUSION

To the extent that the experiment reflects clinical practice, listening to music or other forms of auditory material whilst undertaking microscopy duties is unlikely to be a source of distraction in the cytopathology reading room. From a cognitive perspective, the results are consistent with the notion that high focal-task engagement may have blocked any attentional capture the sound may otherwise have produced.

Opinions of Maltese doctors and pharmacists on medication errors

BACKGROUND

Pharmacovigilance directive 2010/84/EU focused attention on medication errors and encouraged regulators to identify causing and contributing factors.

OBJECTIVES

(1) To study opinions of doctors/pharmacists on factors bearing a causal link to MEs as well as ways to minimise MEs (2) to test whether differences in opinion exist between subgroups of doctors and pharmacists working in community, hospital or office settings.

METHODS

Different questionnaires were circulated to doctors and pharmacists. Respondents were subdivided according to their primary practice.

RESULTS

320 responses were received (204 doctors/116 pharmacists). Differences in opinion reaching statistical significance were observed on distractions from staff, overwork and fatigue, availability of technical resources and having more than 1 doctor on duty. For pharmacists', differences on issues of generic medicine availability and interruptions were found.

CONCLUSION

Distractions and interruptions while executing tasks was flagged as an area requiring attention. Issues of overwork and fatigue affect especially doctors in hospital the majority of which are of the opinion that regulatory control on patient numbers could minimize errors. Increasing technical resources and keeping knowledge up-to-date, addressing overwork and high patient workloads have been identified as important areas when looking to reduce MEs.

Using an integrated information system to reduce interruptions and the number of non-relevant contacts in the inpatient pharmacy at tertiary hospital

Patient care is provided by a multidisciplinary team of healthcare professionals intended for high-quality and safe patient care. Accordingly, the team must work synergistically and communicate efficiently. In many hospitals, nursing and pharmacy communication relies mainly on telephone calls. In fact, numerous studies have reported telephone calls as a source of interruption for both pharmacy and nursing operations; therefore, the workload increases and the chance of errors raises. This report describes the implementation of an integrated information system that possibly can reduce telephone calls through providing real-time tracking capabilities and sorting prescriptions urgency, thus significantly improving traceability of all prescriptions inside pharmacy. The research design is based on a quasi-experiment using pre-post testing using the continuous improvement approach. The improvement project is performed using a six-step method. A survey was conducted in Prince Sultan Military Medical City (PSMMC) to measure the volume and types of telephone calls before and after implementation to evaluate the impact of the new system. Beforehand of the system implementation, during the two-week measurement period, all pharmacies received 4466 calls and the majority were follow-up calls. Subsequently of the integrated system rollout, there was a significant reduction (p > 0.001) in the volume of telephone calls to 2630 calls; besides, the calls nature turned out to be more professional inquiries (p > 0.001). As a result, avoidable interruptions and workload were decreased.

Physicians' Practice of Dispensing Medicines: A Qualitative Study

OBJECTIVES

The physical act of giving medication to patients to administer away from a health care setting, dispensing, is normally performed by pharmacists. Dispensing of medication by physicians is a neglected patient safety issue, and having observed considerable variation in practice, the lead author sought to explore this issue further. A literature review yielded zero articles pertaining to this, so an exploratory study was commenced. The qualitative arm, relating to junior physicians' experience of, and training in, dispensing, is reported here.

METHODS

Focus groups were conducted to explore the beliefs, ideas, and experiences of physicians-in-training pertaining to dispensing of medication. These were recorded and transcribed. The transcriptions were thematically analyzed using the grounded theory.

RESULTS

The emergency department was the most common site of dispensing. No formal training in dispensing had been received. Informal training was variable in content and utility. The physicians felt that dispensing was part of their role.

CONCLUSIONS

Despite being expected to dispense, and the patient safety issues involved in giving drugs to patients to use at home, physicians do not feel that they have been trained to undertake this task. These findings from 1 hospital raise questions about the wider quality and safety of this practice.

Situation analysis of community pharmacy owners in Lebanon

Objective:

To evaluate the current community pharmacists’ interventions and job satisfaction, secondary to the alteration in the financial rewards.

Methods:

A cross-sectional study was carried out, using a proportionate random sample of Lebanese community pharmacy owners from all districts of Lebanon.

Results:

Out of 1618 distributed questionnaires, 1465 (90.5%) were collected back from pharmacy owners. Our study results showed that the monthly sales and profit decreased significantly in the last decade as well as the number of loyal customers (p<0.001 for all). The rent, the total assistant pharmacists’ and employees’ salaries, income taxes, municipality fees, the total bills (electricity, water, cleaning, security) and the disposal of expired products per year significantly increased during the last 10 years (p<0.001). 95% of the owners said they cannot afford to hire any more pharmacists while 45% said they cannot afford buying software for their pharmacies. Finally, 89% of these owners admitted that their situation was better 10 years ago compared to nowadays.

Conclusion:

Most Lebanese community pharmacists are not financially satisfied; their financial situation deteriorated in the last decade. The ministry of Health along with the Order of Pharmacists in Lebanon should cooperate together to resolve this problem since they are two entities responsible for the patient’s health.

An experimental study on the impact of clinical interruptions on simulated trainee performances of central venous catheterization

Background

Interruptions are common in the healthcare setting. This experimental study compares the effects of interruptions on simulated performances of central venous catheterization during a highly versus minimally complex portion of the task.

Methods

Twenty-six residents were assigned to interruptions during tasks that are (1) highly complex: establishing ultrasound-guided venous access (experimental group, n = 15) or (2) minimally complex: skin cleansing (control group, n = 11). Primary outcomes were (a) performance scores at three time points measured with a validated checklist, (b) time spent on the respective tasks, and (c) number of attempts to establish venous access.

Results

Repeated measure analyses of variances of performance scores over time indicated no main effect of time or group. The interaction between time and group was significant: F (2, 44) = 4.28, p = 0.02, and partial eta² = 0.16, indicating a large effect size. The experimental group scores decreased steadily over time, while the control group scores increased with time. The experimental group required longer to access the vein (148 s; interquartile range (IQR) 60 to 361 vs. 44 s; IQR 27 to 133 s; p = 0.034). Median number of attempts to establish venous access was higher in the experimental group (2, IQR 1–7 vs. 1, IQR 1–2; p = 0.03).

Conclusions

Interruptions during a highly complex task resulted in a consistent decrement in performance scores, longer time required to perform the task, and a higher number of venous access attempts than interruptions during a minimally complex tasks. We recommend avoiding interrupting trainees performing bedside procedures.

Multitasking simulation: Present application and future directions

The Accreditation Council for Graduate Medical Education lists multi-tasking as a core competency in several medical specialties due to increasing demands on providers to manage the care of multiple patients simultaneously. Trainees often learn multitasking on the job without any formal curriculum, leading to high error rates. Multitasking simulation training has demonstrated success in reducing error rates among trainees. Studies of multitasking simulation demonstrate that this type of simulation is feasible, does not hinder the acquisition of procedural skill, and leads to better performance during subsequent periods of multitasking. Although some healthcare agencies have discouraged multitasking due to higher error rates among multitasking providers, it cannot be eliminated entirely in settings such as the emergency department in which providers care for more than one patient simultaneously. Simulation can help trainees to identify situations in which multitasking is inappropriate, while preparing them for situations in which multitasking is inevitable.

Analysis of Smartphone Interruptions on Academic General Internal Medicine Wards. Frequent Interruptions may cause a 'Crisis Mode' Work Climate

INTRODUCTION

Hospital-based medical services are increasingly utilizing team-based pagers and smartphones to streamline communications. However, an unintended consequence may be higher volumes of interruptions potentially leading to medical error. There is likely a level at which interruptions are excessive and cause a 'crisis mode' climate.

METHODS

We retrospectively collected phone, text messaging, and email interruptions directed to hospital-assigned smartphones on eight General Internal Medicine (GIM) teams at two tertiary care centres in Toronto, Ontario from April 2013 to September 2014. We also calculated the number of times these interruptions exceeded a pre-specified threshold per hour, termed 'crisis mode', defined as at least five interruptions in 30 minutes. We analyzed the correlation between interruptions and date, site, and patient volumes.

RESULTS

A total of 187,049 interruptions were collected over an 18-month period. Daily weekday interruptions rose sharply in the morning, peaking between 11 AM to 12 PM and measuring 4.8 and 3.7 mean interruptions/hour at each site, respectively. Mean daily interruptions per team totaled 46.2 ± 3.6 at Site 1 and 39.2 ± 4.2 at Site 2. The 'crisis mode' threshold was exceeded, on average, 2.3 times/day per GIM team during weekdays. In a multivariable linear regression analysis, site (β6.43 CI95% 5.44 - 7.42, p<0.001), day of the week (with Friday having the most interruptions) (β0.481 CI95% 0.236 - 0.730, p<0.05) and patient census (β1.55 CI95% 1.42 - 1.67, p<0.05) were all predictive of daily interruption volume although there was a significant interaction effect between site and patient census (β-0.941 CI95% -1.18 - -0.703, p<0.05).

CONCLUSION

Interruptions were related to site-specific features, including volume, suggesting that future interventions should target the culture of individual hospitals. Excessive interruptions may have implications for patient safety especially when exceeding a maximal threshold over short periods of time.

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.

Spring Ahead or Fall Back? Exploring the Nature of Resumption Errors

It has long been known that interruptions can be disruptive, but the details on where people resume an interrupted task have been largely overlooked by the literature. This paper describes an exploratory study to understand where people resume a task following an interruption. The findings suggest that people are significantly more likely to commit an error on the first step immediately following an interruption than on non-interrupted steps. Furthermore, people seem more likely to repeat a step than skip a step during these resumption errors. Finally, this trend toward repeating steps disappears in errors of non-interrupted steps.

Medication Dispensing Errors in Community Pharmacies: A Nationwide Study

The available literature concerning medication dispensing errors provides relatively few studies that focus on community-based pharmacies. This paper presents the results of a nationwide, observation-based study of dispensing errors. Although community-based pharmacies were the primary focus, a small number of health-system pharmacies were also included. Investigators collected information concerning the frequency and type of errors and near errors as well as data regarding a number of task and environmental factors previously correlated with dispensing errors. A total of 5,784 prescriptions were inspected, revealing 91 errors (1.57%) and 74 near errors (1.28%). Errors were categorized as either content (41.76%) or labeling (58.24%) errors. Results are consistent with findings in the available literature. In particular, lighting levels, type of inspection system used (e.g., bar code product verification), number of available employees, and the arrangement of drug stock were significantly associated with both types of errors.

Model-Based Predictions of Interrupted Checklists

The improper completion of a cockpit checklist has contributed to a number of aviation accidents. In many of these cases, it can be shown that interruptions were a contributing factor in the failure to complete the checklist properly. Unfortunately, most studies of interruptions have provided only post-hoc explanations for these failures. Further, research has focused on whether or not tasks are resumed rather than on predictions of where people will resume a task after an interruption. This paper describes several generic models that were used to explore cognitive strategies for handling interruptions. One of these models was then modified to fit the specific real-world task of completing an aircraft checklist. This model produced detailed a priori predictions about where the interrupted checklist will be resumed. The implications of these predictions for task design and for the use of cognitive modeling as an approach to understanding interruptions are discussed.

Distracted Practice: A Concept Analysis

PROBLEM

Distracted practice is a growing concern for all healthcare professionals working in today's complex, technology-rich, acute care hospital environment. Distractions are a threat to patient safety, frequently cited as a contributing factor when reporting an adverse event. The number of new technologies introduced to the healthcare environment has significantly increased the number of distractions. Shrinking resources and the resultant time pressure placed on all practitioners has added to the list of human factors known to be contributing to potential errors. Delivering safe, quality care in this environment has now become a daily challenge for all members of the healthcare team. Distracted practice was found to have no consistent definition in the healthcare literature.

METHOD

Walker and Avant's method of concept analysis was used to develop a preliminary definition and model of distracted practice.

FINDINGS

This analysis includes a definition, characteristics, antecedents, and consequences of distracted practice.

CONCLUSION

More research is needed to fully understand this critical human experience of distracted practice. With additional knowledge we will be able to raise awareness and create interventions to reduce its occurrence among members of the healthcare team. This will positively contribute to the team's efforts to keep all our patients safe while in the hospital. D'Esmond.