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Side tracks on the safety express. Interruptions lead to errors and unfinished… Wait, what was I doing?
November 29, 2012

Problem: If you’re a health professional, it’s hard to get through a single hour of the day without being distracted or interrupted, even when performing critical tasks. For instance, nurses administering medications and pharmacists and technicians dispensing medications are distracted and interrupted as often as once every 2 minutes!(1-2) Physicians are interrupted, too—about once every 5 minutes in an academic emergency department (ED) setting and once every 10 minutes in a community ED setting.(3) Multi-tasking is expected from those being interrupted, and constant distractions and interruptions are generally accepted as the norm in healthcare. However, the argument that distractions and interruptions contribute to medication errors is persuasive in the literature. To cite one study, the risk of any medication error increases 12.7% with each interruption, and the risk of a harmful medication error is doubled when nurses are interrupted 4 times during a single drug administration and tripled when interrupted 6 times.(4) Thus, distractions and interruptions have major consequences in healthcare.

Effects of Distractions and Interruptions
Distractions and interruptions include anything that draws away, disturbs, or diverts attention from the current desired task, forcing attention on a new task at least temporarily. Attending to the new task increases the risk of an error with one or both of the tasks because the stress of the distraction or interruption causes cognitive fatigue, which leads to omissions, mental slips or lapses, and mistakes. An error reported to ISMP a decade ago is still an excellent example of how easy it is to make an error when distracted and interrupted. A nurse who had just measured a dose of liquid chloral hydrate into a cup was interrupted by a pharmacist on her way to the patient’s room. The conversation was social, and the nurse—who often had a cup of coffee in her hand—absentmindedly drank the medication, as if taking a sip of coffee! The nurse had to be driven home.
Distractions and interruptions impact the prospective memory, or the ability to remember to do something that must be deferred.(1) When a person forms an intention, their memory establishes a specific cue to remind them to act. If the task is interrupted and the cue is encountered later, a spontaneous process is supposed to bring the intention to mind. However, individuals are less likely to remember the intention if they are outside the context in which the cue was established.(5) For example, an interruption that causes a nurse to leave the patient’s room decreases the likelihood that the nurse will remember to come back to finish the interrupted task. A study on multi-tasking with computers found that 40% of the time, individuals wandered off in a new direction after the interruption ended.(6) They forgot what they were doing before the interruption. 
If an individual remembers to go back to the initial task, some of the steps may be omitted or repeated, or the entire task may be repeated. For example, a nurse may re-administer a medication, or a pharmacist may dispense a second dose of medication, forgetting that she had already done so. When returning to a task, it takes time for the working memory to get back to where it was before the interruption or distraction.(7) If the task is complicated, individuals who feel pressured may not spend the time it takes for the working memory to catch up, thereby rushing the task and risking errors. In fact, a study on physician distractions found that interrupted tasks were actually completed in less time than if the task had not been interrupted!(4) The researchers suggest that the physicians were rushing, which is especially prone to omissions and other types of errors. New staff are particularly vulnerable to distractions and interruptions because interrupting a new task to do a second task affects how the brain processes and stores the information, thereby compromising the ability to recall the new task correctly at a later date.(8)
Studies have shown that distractions and interruptions early in the completion of a task are more error-prone than those that occur near the end of the task or between subtasks.(9) When interruptions occur at natural breakpoints or transitions between parts of a task, instead of during the busiest moments, errors are less likely. These are also the points at which important notifications may be attended to more closely.

Sources of Interruptions and Distractions
The sources of interruptions most often include people—healthcare staff, patients, and visitors—or medical devices, such as computers, infusion pumps, and phones. The sources of distractions can be auditory (e.g., alarms, noise, overhead pages) or visual (e.g., alerts). Interruptions occur for a variety of reasons, most often for clinical or procedural clarification, notifications, requests, systems issues such as missing medications or other supplies, emergencies, and social conversation. While surveys suggest that health professionals often believe telephone calls and patients represent the greatest sources of interruptions and distractions, actual studies have found that self-induced interruptions during which health professionals themselves initiate conversation with others were a more frequent source of interruptions.(1,10)
Another source is the potential for health professionals to become distracted by electronic devices, including, tablets or notebooks, wireless communication devices (e.g., Vocera), electronic references, and notification systems. In hospitals, many of these devices are used for timely notification of patient or drug information that is needed to provide optimal patient care. Thus, the “interruption” may be useful. Therein lies the rub—health professionals may use these devices for quick access to data, drug information, clinical alerts, and other patient information; but the unintended consequence is that professionals can be glued to the screen and not focused on the patient, even during moments of critical care.(11) And they may not always be doing work.
With connectivity just a click away, health professionals may be tempted to conduct personal business while at work. Listing caregiver distractions from mobile devices as one of the top 10 technology hazards for 2013,(12) ECRI cites an example: While a medical resident was using her smartphone to discontinue anticoagulation, she was interrupted by a personal text message before completing the order. She quickly responded to the message but forgot to go back to finish the order in the electronic prescribing system. Anticoagulation continued unnoticed for days, and the patient developed hemopericardium and tamponade requiring emergency surgery.(13) In a 2010 poll, half of the perfusionists operating bypass equipment admitted to texting during heart-lung bypass procedures.(14) In a 2012 survey, almost half of surgical suite managers had witnessed health professionals distracted by electronic devices, and more than 5% reported that personal use of a mobile device was possibly linked to an adverse event, including wrong-site surgery.(15) Younger staff may be more susceptible to distraction because they have grown up being constantly “connected” via text messaging, instant messaging, Facebook, browsing the Internet, and so on.

Safe Practice Recommendations: While distractions and interruptions in healthcare cannot be fully eliminated, there are steps that can be taken to create a far less chaotic environment for the medication use process.
No Interruption Zone (NIZ). The NIZ uses aviation’s concept of a sterile cockpit in which a discreet area where critical medication tasks are performed is cordoned off with red tape or other visual markers or walls (as with a dedicated medication room) to signify that talking and interruptions are not permitted within the boundaries.(16) These zones can be created around automated dispensing cabinets, drug preparation areas, laminar flow hoods, computer order entry locations, and other areas where critical tasks are carried out.
Do not disturb. For nurses, the Institute of Medicine recommends wearing a visual signal during medication administration, such as colored vests, sashes, or aprons, to signify that they should not be interrupted.(17) This intervention has led to a reduction in medication errors.(1) However, some hospitals may find the intervention unsatisfactory because it is difficult to keep all staff, patients, and visitors informed regarding its intention, and the vest may need to be worn too frequently given medication administration schedules, particularly in critical care areas where nurses may not want to leave the bedside to find a vest. However, if nurses are carrying mobile devices, calls and other notifications can be temporarily transferred to another staff member or the mobile devices can be placed on pause or silence for short periods of undisturbed time. 
Staff education. Ask all staff to avoid interrupting nurses administering medications, physicians during the prescribing process, and pharmacists or technicians who are preparing, mixing, labeling, or checking medications. The health professional should only be disturbed if a significant alteration in a patient’s therapy must be communicated immediately. Also educate staff about the risks associated with distractions from the use of mobile devices.(12)
Best times for necessary interruptions. If interruptions or notifications are necessary when health professionals are prescribing, dispensing, or administering medications, attempt to intervene during transitions between subtasks, such as between patients or doses being prepared or prescribed. Avoid interruptions during the most complex parts of the task.
Checklists. A checklist of important points during lengthy critical tasks can be affixed to work areas for reference when leaving one task and returning to complete it to aid in remembering where the person left off.
Preparation. To minimize task disruption, ensure that all needed supplies and documents are available before prescribing, preparing, or administering medications. For example, all needed supplies should be gathered prior to preparing chemotherapy, or all needed supplies should be available on a medication cart prior to medication administration.System improvements. Identify the sources of common interruptions and remedy any system issues such as frequently missing medications or untimely dispensing of medications. Provide medications to patient care units in the most ready to use form to minimize interruptions associated with mixing, diluting, or crushing medications. Establish a fax, email, or other electronic form of communication between nurses and pharmacists for routine issues that do not require immediate phone contact, or establish a triaging system for incoming phone calls.  
Mobile device management strategy. Obtain input from all health professional stakeholders regarding the appropriate and inappropriate use of mobile devices. Implement a management strategy that addresses appropriate use of mobile devices while minimizing the risks associated with distractions, and identifies which network resources the devices may access and what measures need to be taken to ensure safe use.(12) Any inattentive behavior related to personal business should be treated as an at-risk behavior that requires coaching to promote safe behavioral choices.
Alerts, alarms, and noise. Reduce the frequency of invalid, insignificant, or overly sensitive computer alerts and device alarms to promote the delivery of critical notifications that are necessary and considered. Minimize the noise of overhead pages and other unnecessary chatter in clinical areas.

References
1) Relihan E, O’Brien V, O’Hara S, Silke B. The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Qual Saf Health Care. 2010;19:e52.
2) Silver J. Interruptions in the pharmacy: classification, root-cause, and frequency. Available at: www.ismp.org/docs/SilverJ_SHS2010.pdf.
3) Chisholm CD, Weaver CS, Whenmouth L, Giles B. A task analysis of emergency physician activities in academic and community settings. Ann Emerg Med. 2011;58(2):117-22.
4) Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-690.
5) Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform. 2009;78(5):293-307.
6) ASPsoftware. Daley T. Wasting productive time on interrupts? Time Savers Wasting Time through Interruptions. April 2006;1-3. Available at: www.ismp.org/sc?id=137.
7) Altmann EM, Trafton JG. Timecourse of recovery from task interruption: data and a model. Psychon Bull Rev. 2007;14(6):1079-84.
8) Foerde K, Knowlton BJ, Poldrack RA. Modulation of competing memory systems by distraction. Proc Natl Acad Sci USA. 2006;103(31):11778-83.
9) Adamczyk PD, Bailey BP. If not now, then when? The effects of interruption at different moments within task execution. In CHI 2004 Proceedings. New York: ACM Press, 2004:6(1):271-8.
10) Fry MM, Dacey C. Factors contributing to incidents in medication administration. Part 2. Br J Nurs. 2007;16(11):676-81.
11) Richtel M. As doctors use more devices, potential for distraction grows. New York Times. Dec. 14, 2011.
12) ECRI. Top 10 technology hazards for 2013. Health Devices. 2012;41(11):1-23.
13) Halamka J. Order interrupted by text: multitasking mishap. Web M&M. Dec. 2011.
14) Smith T. Darling E, Searles B. 2010 survey on cell phone use while performing cardiopulmonary bypass. Perfusion. 2011; 26(5):375-80.
15) Patterson P. Smartphones, tablets in the OR: with benefits come distractions. OR Manager. 2012;28(4):1,6-8,10.
16) Lewis TP, Smith CB, Williams-Jones P. Tips to reduce dangerous interruptions by healthcare staff. Nursing 2012. 2012;42(11):65-7.
17) Committee on the Work Environment for Nurses and Patient Safety. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press, 2004.

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