Mitigation of Interruption Effects on Delivery of High-Risk Medical Procedures

Issue
Many healthcare settings (e.g., emergency departments, intensive care units, pharmacies) are intense and interrupt-laden. Distractions and interruptions have been identified as frequent contributors to medication errors, and the injuries that results from them^1,2. Medication errors can be made at various stages throughout the medication process: ordering, prescribing, transcribing, dispensing, and/or administration stages.

The safety impact of medication errors may vary depending on the stage of the medication process at which the error occurs. If errors occur at the medication prescribing, transcribing or dispensing stages, healthcare providers may notice and correct the mistake before it reaches the patient. If, however, the error occurs at the administration stage and reaches the patient, there may be no chance of recovering from the error. Therefore, the administration stage is a high-risk procedure. This is little information available, however, on the nature, causes, and effects of interruptions on medication administration. For this reason, the Canadian Patient Safety Institute (CPSI) awarded a grant to the Healthcare Human Factors Group to conduct research on this issue.

Methods
Multi-phase study:

Shadowing
Lab Study #1
Intervention Design
Lab Study #2
Intervention Implementation

Phase 1: Shadowing
The first phase of the project involved shadowing healthcare providers as they administered medications, documenting the frequency, nature and timing of interruptions, allowing researchers to identify the current state of interruptions and examine the impact of interruptions on workflow.

Details
Participants: 17 nurses
Location: Princess Margaret Hospital Chemo Daycare Centre
Duration: Observed over a period of 3 hours each

Results
The majority of interruptions occur when nurses are performing drug verification tasks, vital checks and programming infusion pumps:

Frequency of Interruptions - Safety critical tasks

The main sources of interruptions are coworkers, the patients nurses are caring for and pumps:

Sources of Interruptions - Safety critical tasks

The shadowing results also highlighted typical outcomes of interruptions on high-risk medical procedures; among them are: increased task time, delays, omissions as well as multi-tasking.

Phase 2: Lab Study #1
The second phase of the project involves the replication of a chemo daycare unit in a simulation lab in the Centre for Global eHealth Innovation. The lab study consists of mocking-up interruption scenarios and measuring the effects of interruptions on healthcare providers' ability to follow best practice procedures when administering medications to patients.

Details
Participants: 18 nurses
Location: Centre for Global eHealth Innovation Usability Labs
Duration: Two-hours session

Lab Study #1 - Set-up

Lab Study #1 - View from observation room

Results
In-progress

Phase 3: Intervention Design
The third phase of research will consist of conducting focus groups with healthcare providers to design interventions that mitigate the effects of interruptions on medication administrations observed during Phase 2. The central premise of involving healthcare providers in the development of mitigation interventions is that the best-designed solutions result from understanding the needs of the people who will use them.

Details
Participants: Approximately 15 healthcare providers
Location: TBD
Duration: TBD

Results
Coming soon

Phase 4: Lab Study #2
The goal of the second lab study is to measure the effectiveness of the mitigation interventions, in terms of facilitating providers' adherence to best practice principles, when administering medications. Healthcare providers will be trained in the use of the interruption mitigation interventions. Based on the results of this phase of research will provide insight as to the best way to implement the chosen mitigation interventions in the clinical environments.

Details
Participants: Approximately 16 nurses
Location: Centre for Global eHealth Innovation Usability Labs
Duration: TBD

Results
Coming soon.

Phase 5: Intervention Implementation
During the fifth phase of research, the chosen mitigation interventions will be implemented in two chemotherapy daycare centres located in different jurisdictions. Human Factors Specialists will conduct follow-up observations following implementation to assess whether the mitigation interventions require amendment and the extent to which they have been accepted by healthcare providers.

Details
Participants: TBD
Location: Princess Margaret Hospital in Toronto and the Juravinski Cancer Centre in Hamilton
Duration: Six months

Results
Coming soon

References

Related Research:

General overview:
Kohn LT, Corrigan JM, Donaldson MS, (Eds.). To Err is Human: Building a Safer Healthcare System. Institute of Medicine. Washington, D.C.: National Academy Press, 2000.

Hickam D, Severance S, Feldstein A, et al. The effect of health care working conditions on patient safety. Rockville, MD: Agency for Healthcare Research and Quality, 2003.

United States Pharmacopeia. Summary of Information Submitted to Medmarx in the Year 2001: A Human Factors Approach to Understanding Medication Errors. 2001.

Beyea, SC. Distractions, interruptions, and patient safety. AORN Journal 2007 July; 86(1):109-112.

Theory:
Grundgeiger T, Sanderson P. Interruptions in healthcare: Theoretical views. Int J Med Inf 2009 May;78(5):293-307.

Parker J, Coiera E. Improving clinical communication: A view from psychology. Journal of the American Medical Informatics Association 2000;7(5):453-61.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Work Interruptions and Their Contributions to Medication Administration Errors: An Evidence Review. Worldviews Evid Based Nurs 2009;6(2);70-86.

Field studies:
Redding DA, Robinson S. Interruptions and Geographic Challenges to Nurses' Cognitive Workload. J Nurs Care Qual 2009;24(3):194-200.