EXECUTIVE SUMMARY

EPs were interrupted 12.5 times every hour on average, according to a recent study. EPs rejected or delayed interruptions less than 2% of the time. Some strategies:

• Use placeholders to get back on task quickly;
• Finish the current task if interruptions are not emergencies;
• Train residents with interruptions to mimic the ED setting.

EPs are interrupted 12.5 times every hour on average, according to a recent study.¹ “The fact that interruptions are highly disruptive and increase error is well-established in the cognitive science literature,” says Raj Ratwani, PhD, who led the study.

Previous research has shown that interruptions produce as much as a 10-fold increase in error rates.² “We wanted to see how this plays out in a healthcare setting, specifically the ED, where there is high workload,” says Ratwani, acting director and scientific director of the MedStar National Center for Human Factors in Healthcare in Washington, DC.

Researchers observed 18 attending EPs in three different urban academic EDs for two hours. The number of interruptions, source of interruptions, tasks interrupted, and use of interruption management strategies were analyzed. Some key findings:

• The vast majority of interruptions (87%) were in person from other staff: nurses, residents, technicians, and other EPs. Other interruptions came from phone calls (9%), patients (1%), or “other,” (2.5%), including devices and pages.
• At the time they were interrupted, EPs were working on a computer 44% of the time, handling paperwork 20% of the time, conversing with clinical staff 15% of the time, multitasking 14% of the time, and talking with patients 3% of the time.
• EPs usually (76% of the time) stopped what they were doing immediately and switched to the interruption task. “Only about a quarter of EPs continued the primary task while the interrupting task was being performed,” Ratwani notes.

EPs’ Surprising Response

The researchers were curious about strategies EPs use to cope with constant interruptions in the ED setting. “What we’ve seen in the past is that people have developed their own mechanisms to handle interruptions. We were interested to see if that was the case in emergency medicine,” Ratwani explains.

The researchers were very surprised at the high rate at which EPs accepted the interruption. EPs almost never rejected or delayed interruptions. They did so less than 2% of the time.

“That was shocking to me,” Ratwani says. The researchers expected to see EPs give themselves a moment to complete the task they were engaged in, or arrive at a good stopping point. Instead, the EPs stopped what they were doing and responded immediately to their colleagues’ requests or demands.

“It shows there is a climate of trusting team members that their requests have a higher priority or higher acuity,” Ratwani offers. “But at the same time, we know that has a cognitive cost.”

Switching gears too quickly carries repercussions for patient safety. “Sometimes, EPs fall into a reactive mindset, where they are responding to all of the different stimuli and are not able to take a step back and prioritize as much,” Ratwani laments.

Given the fact that interruptions will continue in the ED setting, better management by EPs potentially can save lives, Ratwani says. He offers these strategies:

• Reduce interruptions.

For example, EPs can avoid putting themselves in situations where someone is likely to interrupt them by documenting or placing orders while in the patient room instead of at the open workstation.

• Avoid saying, “Come back and see me in a few minutes.”

“You’ve just invited an interruption in a few minutes,” Ratwani warns.

• Use placeholders to get back on task quickly.

For instance, the EP could place a mouse cursor where work on a screen was last updated before switching to another task. Or, the EP can place a Post-it note on the screen where the field for a medication order is located. This visual cue triggers the memory that the EP was ordering a medication for this patient.

• Delay interruptions for a few seconds by waiting for a natural break point.

Obviously, this would not work if a patient is coding. However, the vast majority of ED interruptions are not true emergencies. If the EP is interrupted in the middle of typing digits for the number of tablets or dosage, the EP is going to struggle to come back to the task. Instead, the EP can enter the dosage, turn their attention to the new task, then complete the medication order.

“Oftentimes, interruptions are not high priority and can wait a few seconds to be attended to,” Ratwani adds.

• Train residents with interruptions so they get better at resuming tasks.

Medical students typically practice procedures such as intubation in simulated, controlled environments that are quiet and without any interruptions. This is nothing like the ED setting. “If you train with interruptions, you can develop strategies for how to resume tasks more easily so you are less prone to errors,” Ratwani says.

Link to Lawsuits

There is no hard data to demonstrate the link between ED interruptions and malpractice litigation. However, it’s still possible to discern.

“Most of the time, when we are looking at what are the contributing factors that harm patients and lead to a claim, the deep details are sometimes not available,” Ratwani explains. Even if a medication error happened because of an ED interruption, claims aren’t categorized this way. Instead, lack of attention, lack of focus, or (more broadly) human error are identified as contributing factors.

“Unfortunately, it’s very hard to document whether a specific interruption was a true causal factor,” Ratwani says.

Still, it is well-known that interruptions increase the likelihood of error. “And they are incredibly frequent in the ED. So, I think we can draw the conclusion that they are going to lead to claims,” Ratwani offers.

In analyzing patient safety event reporting systems, in which clinicians report near misses or actual harm events, Ratwani has seen a fair amount of people explicitly make note of a distraction or interruption. In one report, a nurse described lowering the side rail of a patient’s bed, and getting interrupted by a resident with a question. The patient fell out of the bed and was injured.

It’s not always possible to identify the exact interruption that led to an ED malpractice claim, of course. Still, the conclusion can be drawn that interruptions are linked to adverse events and litigation against EPs.

“Considering many patient safety reports have involved interruptions, there’s a clear link to malpractice litigation,” Ratwani says. “We know that interruptions are definitely involved in these events.”

REFERENCES

1. Ratwani RM, Fong A, Puthumana JS, Hettinger AZ. Emergency physician use of cognitive strategies to manage interruptions. Ann Emerg Med 2017;70:683-687.
2. Ratwani RM, Trafton JG. A real-time eye tracking system for predicting and preventing postcompletion errors. Human-Computer Interaction 2011;26:205-245.

SOURCE

• Raj Ratwani, PhD, Acting Center Director/Scientific Director, MedStar National Center for Human Factors in Healthcare, Washington, DC. Phone: (202) 244-9815. Email: Raj.M.Ratwani@medstar.net.