R E V I E W S & A N A LY S E S Distractions and Their Impact on Patient Safety Michelle Feil, MSN, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority The definition of “distract” is “to draw or direct (as one’s attention) to a different object or in different directions at the same time.”1 Distraction is especially detrimental to human functioning in situations requiring cognitive processing of large amounts of complex and rapidly changing information. Such situations occur almost constantly in healthcare settings. When presented with new information, the mind of the health- ABSTRACT care worker must be able to focus attention and encode information to be retrieved at a later time. Diverting attention during these key points of information encoding or Distraction is a common source of retrieval may result in human error.2 potential error that is well established within the fields of human factors research and cognitive psychology. DISTRACTIONS IN PENNSYLVANIA High levels of distraction in healthcare A query of the Pennsylvania Patient Safety Authority’s Pennsylvania Patient Safety settings pose a constant threat to Reporting System (PA-PSRS) database for events reported in 2010 or 2011 containing patient safety. New technologies have the terms “distract,” “interrupt,” or “forgot” produced 1,202 reports, of which analysts increased the number and types of identified 1,015 reports describing events that could be attributed to distraction. The distractions present in these settings. majority of these events were reported as medication errors or errors related to proce- Analysis of reports submitted to the dures, treatments, or tests (see Figure). Nearly all events were reported as Incidents Pennsylvania Patient Safety Authority (i.e., events resulting in no harm to patients). However, it is important to note that in 2010 and 2011 containing relevant even in cases of no harm, additional costs may be incurred during follow-up. For terms, namely “distract,” “interrupt,” or example, nearly one in five events (17.7%, n = 180) were reported with a harm score of “forgot,” identified 1,015 reports that D, which is defined as an event that requires monitoring to confirm that it results in could be attributed to distraction. The no harm and/or requires intervention to prevent harm.3 majority of events were classified as medication errors (59.6%), followed by Of the 13 Serious Events (i.e., events resulting in harm to patients) reported, the major- errors related to procedures, treatments, ity were split equally between medication errors and errors related to procedures, treat- or tests (27.8%). Thirteen events were ments, or tests. See Table 1 for events reported according to event type and harm score. reported that resulted in patient harm. A total of 40 reports specifically mention distractions from phones, computers, or other technologic devices contributing Figure. Event Reports to the Pennsylvania Patient Safety Authority Attributed to to errors. This article examines the Distraction, by Event Type, 2010 through 2011 broader issue of distractions that cause medical errors and outlines 11 strategies for decreasing the potential 24 (1%) for distraction and harm. These risk (2%) Medication error 70 reduction strategies include developing (7%) Adverse drug reaction systems and processes that reduce or (not a medication error) eliminate distractions and teaching Equipment, supplies, or devices effective techniques for handling distractions. (Pa Patient Saf Advis 2013 282 Error related to procedure, Mar;10[1]:1-10.) (28%) treatment, or test 605 Complication of procedure, (60%) treatment, or test Transfusion 16 (1%) Other/miscellaneous MS13088 7 (1%) Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 1 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 1. Serious Event Reports to the Pennsylvania Patient Safety Authority Attributed to identification of the reason for the lapse Distraction, by Event Type and Harm Score, 2010 through 2011 in memory or attribute the reason for the NO. OF memory lapse to a general cause, such as EVENT TYPE BY HARM SCORE REPORTS being “busy” (5.4%, n = 55). Use of this term may reflect multitasking. In fact, Harm score E: An event occurred that contributed to or 12 resulted in temporary harm and required treatment many of the report narratives describe this or intervention phenomenon using a variety of terms. Of note, 40 event reports (3.9%) specifically Medication error 5 identify distractions from phones, Extra dose 1 computers, or other technologic devices as Wrong dose (overdosage) 2 contributing to errors. Wrong rate (intravenous) 2 Event Reports Adverse drug reaction (not a medication error) 1 The following examples from PA-PSRS Error related to procedure/treatment/test 4 reports illustrate the variety of events Surgery/invasive procedure problem—other 1 attributed to distraction and the resulting Radiology/imaging test problem—wrong site 1 influence on various clinicians. Radiology/imaging test problem—other 1 Pharmacy Other 1 I saw that unusual custom traces Complication of procedure/treatment/test 2 were ordered. I informed the techni- cian to make the special dilutions Complication following surgery or invasive (which was done without incident). 1 procedure—other When I entered the prescription into Other 1 the compounding computer, I forgot Harm score G: An event occurred that contributed to 1 to “zero-out” the neonatal trace mix, or resulted in permanent harm which provides the standard traces. Error related to procedure/treatment/test 1 Because of other unusual events in the area, I did not catch my error Laboratory test ordered, not performed 1 that day, and the double-dose was Total events with harm 13 dispensed. (Persons were talking to me while I was entering and while I was checking, and I was stressed due Sixty-six percent (n = 672) of reports identified within PA-PSRS, but analysis to a drug shortage and multiple new describe distraction of nurses as directly revealed the majority of narratives were procedures required, and I was striv- contributing to the events. Fewer reports written in the first- or third-person per- ing to meet delivery deadlines despite identify the following individuals as the spective of nurses. late-received adult orders.) I am very distracted parties: laboratory technician/ sorry. In the future, if someone is The majority of events do not directly phlebotomist (7.9%, n = 80), patient talking to me while I am entering or identify the source of distraction; (6.7%, n = 68), pharmacist (6.7%, n = 68), checking a prescription, I will stop however, the following key search terms physician (5.3%, n = 54), radiology techni- until I can fully concentrate. I caught appeared in the event reports (with their cian (2.3%, n = 23), secretary (1.4%, my mistake when I entered the new frequency provided in parentheses): n = 14), respiratory therapist (1.2%, n = 12), prescription for today. forgot (80.8%, n = 820), distract (14.1%, nursing assistant (0.9%, n = 9), nurse Anesthesia n = 143), and interrupt (7.3%, n = 74). practitioner/nurse anesthetist/physician’s Together, these percentages total greater Patient had PCA [patient-controlled assistant (0.6%, n = 6), and “other” than 100% because, in a small number analgesia] and nerve block. Pumps (4.0%, n = 41). Caution must be taken in of reports, more than one of the key were side by side. The anesthesiolo- interpreting these percentages, as nearly search terms was identified. In general, gist identified the nerve block pump all events appear to have been reported the narratives describe some element and tubing to administer a bolus via by nurses. The role of the reporter is not of patient care being forgotten without Page 2 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority the route. He was distracted and, distracted by a fellow technologist’s Transcribing upon returning to give bolus, did not question regarding another patient. Orders were written for patient A, reidentify the pump. He programmed I returned to the workstation to faxed to satellite pharmacy, and the wrong pump for the bolus. The identify the image. I glanced at the processed. The pharmacist began patient received HYDROmorphone highlighted first name of the patient entering the orders and was then PCA bolus, requiring naloxone rescue. I had pulled up and assumed that I interrupted by nurse taking care of Laboratory had the correct patient information. I patient B. The pharmacist pulled sent the image across. The next day it up the profile of patient B to answer While logged into this patient’s report was brought to my attention that the screen, I inadvertently viewed the questions. At that time, he finished image was not in the computer sys- processing orders but entered them slide of another patient and reported tem. When looking for the exam on the results from that slide. I immedi- on patient B instead of patient A. the workstation, the patient was not The error was found within one ately realized my error and notified listed. I thought through what I might the nurse taking care of the patient. hour, and the orders were corrected. have done and looked for a patient Unfortunately, the nurse taking care I was distracted and trying to do too with a similar first or last name close much at the same time. of patient B confirmed, charted, and to my patient and discovered that I gave the medications to patient B. Nursing had entered the results for the wrong patient and misidentified the results Preparation and Dispensing [The night before, the] patient was as an abdominal x-ray. The patient was ordered 1100 mg of a ordered to have a potassium level drawn, with the results to be called to chemotherapy agent. The pharmacist the attending [physician’s attention]. Medication Errors pulled two 1 gram vials to prepare It was learned the following morning More than half of the events reported the dose, then realized that we carry that the test had not been ordered. (59.6%, n = 605) describe distractions 500 mg vials and pulled a 500 mg The nurse had gotten distracted with during the medication administration vial also. He forgot to put one of the seven admissions in eight hours and process that were associated with medi- 1 gram vials back and used all three missed the order. cation errors (see Table 2). Within this vials to prepare the dose. The patient category, the largest percentage of events ended up receiving 2100 mg of the Surgeon drug. The pharmacist performing the involved dose omissions (46.8%, n = The assisting surgeon was plac- 283), followed by errors with some aspect double check confirmed the calcula- ing a central venous catheter. The of medication administration labeled tion and verified that there was a procedure was interrupted . . . prior as “wrong” (33.9%, n = 205). The two 1 gram vial and a 500 mg vial used to getting started by a nurse asking most frequently reported errors of this to prepare the dose. He did not notice when the doctor would be coming type were wrong time (n = 49) and wrong the other vial and assumed that the to the OR [operating room]. She dose/overdosage (n = 47). Examples of other vials were sterile water vials for informed him she would be there in distraction can be found impacting all reconstitution. The next day, the phar- 30 minutes. After closing the door disciplines and at every step involved in macist who prepared the dose went to and placing the “Do Not Enter” sign the medication administration process. reorder the drug and realized his error. up, the anesthesiologist came into Administration Prescribing the room and again asked when she would be coming to the OR. She told Physician entered midazolam order The patient had a heart rate in the him that she would be there as soon incorrectly. Physician intended to 170s. The physician ordered metopro- as she found a vein. I turned to get write for 10 mg but scrolled to the lol 2.5 mg IV [intravenous] x 1 dose. something and heard the doctor yell bottom of the electronic list, ordering The nurse pulled the dose from the “ouch.” When I turned back around, 15 mg. Child’s weight would indicate automated dispensing cabinet and I saw that she was pulling the scalpel maximum standard dose of 10 mg. scanned it. Before he had a chance out of her finger. Physician was distracted during entry to draw up the medicine, he was by another clinical question. distracted by another patient. When Radiology he came back to his workstation, he Patient was ordered a stat chest x-ray. ended up drawing up 2.5 mL from I began to run the x-ray and was an insulin vial and giving it to the Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 3 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S patient. He realized the error, and folder. The folder was found two days However, with more elaborate encoding the doctor was notified; dextrose was later and the provider was notified. of information, less information is lost given and fingerstick blood glucose The patient is to be scheduled for an over time. “Working memory” is a specific testing was ordered. The blood sugar ablation procedure. form of memory that holds on to small dropped as low as 52 but returned to Following laboratory test problems and pieces of information, for a few seconds at normal by 2 p.m. “other,” the remaining subcategories a time, as people cognitively process them represented in the reports consisted of for encoding. Divided attention at the Errors Related to Procedures, problems relating to surgery or invasive time new information is being encoded Treatments, or Tests procedures (15.6%, n = 44), radiology or directly interferes with “working memory” The next most frequently reported event imaging tests (11.0%, n = 31), respiratory and is the first point at which distraction type associated with distraction was error care (3.5%, n = 10), referrals or consults interferes with memory.2 related to procedures, treatments, or tests (1.4%, n = 4), and dietary issues (0.7%, Distraction also creates problems during (see Table 2), with 27.8% (n = 282) of re- n = 2). information retrieval. Divided attention ports falling into this category. Within this at this point results in a failure to category, laboratory test problems accounted DISCUSSION remember information that was either for the largest percentage of events (45.0%, never encoded properly or is available in n = 127). The two most commonly reported Distraction and Memory memory but overlooked.2 laboratory test problems were test ordered Memory loss is common to all humans. A Distraction is of particular concern to and not performed (n = 36) and result miss- certain amount of information is expect- “prospective memory,” or remembering ing or delayed (n = 30). ed to be lost over time (a phenomenon to do things in the future. This form of Following laboratory test problems, the labeled “transience”) with the rate of for- memory can be event-based (i.e., when X subcategory of “other” contained the sec- getting being highest immediately follow- happens, do Y) or time-based (i.e., do Y at ond-highest number of reports in this cat- ing the initial encoding of information. a specific time in the future). Event-based egory (22.7%, n = 64). Close examination revealed that most reports labeled “other” Table 2. Reports to the Pennsylvania Patient Safety Authority Attributed to Distraction for refer to errors surrounding procedures, the Two Most Frequently Reported Event Types, 2010 through 2011 treatments, or tests performed by nursing staff that were not medication-related, nor EVENT TYPE NO. OF REPORTS did they fit clearly into the existing subcat- Medication error 605 egories. Examples are as follows: Dose omission 283 Nurse prepared infant’s 17:00 feed- Wrong (e.g., wrong drug, wrong rate, wrong route) 206 ing in syringe, then was interrupted Extra dose 54 to provide care to another infant. Nurse overlooked feeding and noted Monitoring error (includes contraindicated drugs) 23 omission at 20:00 feeding. Doctor Other 18 notified; no adverse outcome. Prescription/refill delayed 11 Patient with a known history of SVT Medication list incorrect 7 [supraventricular tachycardia] called Unauthorized drug 3 and left a message on our clinic voice mail that she had to download her Error related to procedure/treatment/test 282 EKG [electrocardiogram] tracings. Laboratory test problem 127 The pacemaker technologist recorded Other 64 the tracings into the database and printed the tracings when he noted Surgery/invasive procedure problem 44 that the patient was in rapid SVT. Radiology/imaging test problem—wrong site 31 He then placed the tracings in a Respiratory care 10 folder to show the provider; however, Referral/consult problem 4 he got distracted with other things and charts got placed on top of the Dietary 2 Page 4 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority cues are less likely to be forgotten, but competing priorities and completing perceived by the clinicians themselves.9 problems occur when attention is diverted necessary tasks is an essential skill for Differences in frequency of interruptions at the time of the event. Time-based cues healthcare workers. Multitasking creates and prevalence of multitasking found in require self-initiated recall and are more a stream of interruptions that may in fact the clinical literature are due to variation likely to be forgotten without converting be necessary and may increase efficiency. in study designs and definitions for these them to events (e.g., setting an alarm on However, more research is needed on the variables. The psychological literature on a watch converts a time-based cue to an optimal level of interruptions that mini- interruption as it correlates to patient event-based cue—“turn off the Heparin mize error and maximize efficiency.4,5 safety is more consistent in this respect. infusion at 5 p.m.” becomes “when the Unfortunately, there is a very real limit The six experimental variables most alarm sounds, turn off the Heparin infu- to the ability of the human brain to often studied are working memory load, sion”). Of note, the event-based cue must multitask. Cognitive neuroscientists have interruption similarity, interruption posi- contain sufficient information about what identified a specific region of the brain tion, interruption modality, practice/ is to be done, and must be available at the responsible for encoding and retrieving experience, and interruption-handling time necessary, in order to be effective. information, particularly in relation to strategies.5 The implications for clinicians Ideally, these events should also be dis- working memory. This region of the brain related to each of these experimental vari- tinct (e.g., infusion pump alarms are set is unable to process more than one task ables are shown in Table 3. with different tones to indicate the com- simultaneously, severely limiting human pletion of an infusion versus indicating capacity for perception and decision mak- Sources of Distraction the battery charge is low and the pump ing in multitasking situations.6 Interruptions or distractions can be needs to be plugged into a wall outlet). defined as self-initiated or other-initiated. Observational studies of nurses and Research has shown the prevalence of self- Multitasking and Interruption physicians have been conducted that initiated distraction ranges from 28%10 have found multitasking to be highly Balancing multiple tasks, also known as to 38%,7 while other-initiated distraction prevalent—with interruptions occurring multitasking, is a universal and constant ranges from 34% to 69%.10 In studies of anywhere from 1.4 times per minute7 to challenge in healthcare settings. Being able distractions and medication errors, the once every 14 minutes8—and observable to continually process incoming informa- majority of interruptions were found to be multitasking occurring more often than tion while balancing and responding to self-initiated by nurses or other members of Table 3. Top Six Experimental Variables Identified in the Psychological Literature Investigating Interruptions and Their Implications for Clinicians EXPERIMENTAL VARIABLE IMPLICATIONS FOR CLINICIANS Working memory load Interruption during times of high working memory load is associated with decreased performance of the primary task. Interruption similarity Interruption that is similar to the primary task is more disruptive than a dissimilar interruption. Interruption position Interruption occurring during task performance is more detrimental to performance than interruption occurring between tasks. Interruption modality Interruption presenting through a modality different from the primary task (e.g., auditory versus visual) is less disruptive to performance than interruption presenting through the same modality. Practice/experience Practice of the primary task is important to procedural tasks because it increases association between steps in the primary task process, freeing up cognitive resources to be able to handle interruption. Practice of interruption-handling strategies is important to decision-making tasks because it improves performance of the primary task. Interruption-handling strategies Being able to control when to deal with interruption is less disruptive than having no control. Task performance and effective response to interruption are improved when clinicians have a repertoire of strategies for handling interruption. Source: Li SY, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implications. J Am Med Inform Assoc 2012 Jan-Feb;19(1):6-12. Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 5 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S the nursing team, through face-to-face inter- doctoring” is a term recently coined in Studies examining the impact of cell action, occurring for purposes of patient the media to describe the interruptions phone use on driving may inform research management, and of short duration.11 to workflow caused by the introduction on the impact of cell phone and smart- Self-initiated distraction may also be the of new technological devices in the clini- phone use in the clinical setting. These by-product of increased intrinsic cognitive cal setting. This has been elevated to new studies have shown cell phone use to be load, which is determined by the com- levels of concern within the healthcare as detrimental to driving performance plexity of information being processed. community and the general public due to as operating a vehicle while intoxicated. In other words, the internal processing the widespread implementation of com- This impact on driving ability appears to of complex information creates a distrac- puterized provider order entry (CPOE) be due to the diversion of attention away tion that interferes with processing other systems and electronic medical records, from the primary task of driving, regard- information. Other-initiated distractions along with the growing use of cell phones less of whether or not a hands-free device may be a source of increased extraneous and smartphones.14-16 In fact, distractions is used.20 cognitive load, determined by the kind from smartphones and other mobile Investigation of this phenomenon is and amount of new information being devices have been identified for the first just beginning in healthcare. Surveys of perceived and encoded. Decreasing the time as one of the top 10 health technol- clinicians are being published that show cognitive load required for either has ogy hazards for 2013 by ECRI Institute.17 that cell phone and smartphone use is been shown to free up cognitive resources A case study published in December 2011 prevalent, with the majority of clinicians necessary for the other12 (i.e., decreasing by the Agency for Healthcare Research voicing concern over the significant poten- the difficulty level of the primary task and Quality (AHRQ) highlights just how tial safety risks they introduce. There is a increases one’s ability to handle interrup- serious the impact of these distractions generational difference found across sur- tions or distractions without impairing can be in the healthcare setting: veys, with older clinicians reporting less performance, while decreasing interrup- During rounds with the attending, trust of the new technology. Interestingly, tions and distractions increases one’s a medical resident was using a clinicians report witnessing others being ability to complete tasks that require more smartphone to access the CPOE to distracted or committing errors related complex cognitive processing). discontinue an order for warfarin. The to cell phone or smartphone use at rates A common source of self- or other-initiated resident was distracted by an incoming higher than they report for themselves.21,22 distraction is communication of infor- personal text message and failed to com- This mirrors the findings in studies of mation irrelevant to the primary task plete her primary task—discontinuing cell phone use and driving showing that at hand. In an observational study of the warfarin order. The patient con- drivers did not perceive the detrimental distracting communications in the OR, tinued to receive warfarin for the next impact that cell phone use was observed psychologists observed for case-irrelevant three days. As a result, the patient to have on their driving performance.23 communications (CICs). Half of all CICs developed hemopericardium requiring Lack of insight into the impact technol- consisted of “small talk.” Although sur- emergency open heart surgery.18 ogy is having on performance and patient geons initiated and received the majority In a large study of computer-related safety may explain the low number of of CICs, visitors to the OR initiated CICs patient safety incidents, 55% of incidents reports in PA-PSRS that specifically men- with the highest levels of distraction. Also, were attributed to technical problems tion these sources of distraction. Out of communications directed to nurses and (i.e., hardware, software, or networking the 1,015 reports involving distractions, anesthetists provided higher levels of dis- infrastructure problems), while 45% were 10 identify phones as the source of dis- traction than communications directed due to human-computer interaction. The traction, 15 identify computers, and to surgeons.13 majority of technical problems resulted 15 identify other technologies (e.g., auto- in delays or failures to complete clinical mated medication dispensing cabinets, Distraction Due to Technology tasks. As described in the AHRQ case infusion pumps). Anything that diverts attention away from study, the majority of human-computer the primary task is a source of distraction. interaction problems were related to data RISK REDUCTION STRATEGIES Sources of distraction can be broadly entry (e.g., incorrect or missing data, fail- Effort should be made to limit distrac- attributed to individuals (e.g., clinicians, ure to update data). High cognitive work- tions in healthcare settings whenever patients, family members) or to technol- load and multitasking were highlighted as possible. However, total elimination of ogy (e.g., medical equipment, computers, contributing factors.19 distractions is not an achievable goal. communication devices). “Distracted Page 6 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority Dr. Atul Gawande, author of The Checklist infusion pump to deliver an intrave- that written reminders contain suf- Manifesto, summarized the challenge fac- nous anticoagulant). ficient information about what is to ing modern healthcare as follows: “Medi- — Designate routinely encountered be done and that they are placed in cine has become the art of managing tasks that are not to be interrupted, a location that will be visible at the extreme complexity—and a test of whether and develop a system to communi- time the task needs to be completed2 such complexity can, in fact, be humanly cate when staff are engaged in these (e.g., write a note to call for more mastered. . . . Substantial parts of what tasks10,27,30,31 (e.g., close the door bags of bladder irrigation fluid and hospitals do . . . are now too complex for to the patient’s room and post a attach it to the second-to-last bag in clinicians to carry them out reliably from sign instructing other staff to avoid the case that is currently being used). memory alone.”24 Checklists are just one interruptions when performing an — Batch communications to minimize of the strategies suggested to ameliorate invasive procedure at the bedside). distraction to the recipient10,27 (e.g., the impact of distraction in healthcare — Minimize interruptions during per- use a report sheet to communicate settings. Mindfulness meditation training formance of any tasks that place high missing medications for a nursing is another such strategy, one that has been demands on working memory5,27 unit to pharmacy rather than hav- found to improve focused attention and (e.g., close the door to the patient’s ing each nurse call the pharmacist working memory while effectively manag- room and silence or forward any individually). ing distractions—particularly in multitask- calls when performing an unfamiliar — Do not batch tasks for multiple ing situations.25,26 These and other risk procedure for the first time, select patients concurrently5 (e.g., do not reduction strategies are suggested to avoid and prepare medications in a dedi- prepare medication for more than the detrimental effects of variables shown cated medication room instead of one patient at a time, avoid switch- in Table 3 that contribute to increased at busy nurses’ stations or in high- ing back and forth between patient distraction and decreased performance: traffic hallways). electronic records when entering — Educate clinicians about distraction — Practice tasks, particularly those new orders in a CPOE system). and its potential detrimental effect that are complicated or known to be — Provide environmental cues to assist on patient safety.10,27 distraction-prone5 (e.g., encourage in recovery from distraction in order — Raise awareness of the potential for preceptors to seek out opportunities to complete the primary task5,24,30,31 distraction, and promote vigilance during the orientation period for (e.g., using checklists, building through sharing deidentified nar- novice staff to perform tasks that are CPOE systems that alert prescribers ratives of patient safety events and encountered infrequently in their when an order has been partially near misses that occurred due to clinical area, provide opportunities entered but abandoned after a distraction.28,29 to role-play distraction-prone clinical period of inactivity). — Teach clinical staff interruption- scenarios in simulation training). — Use concepts from human factors handling strategies5 (e.g., teach staff — Develop and utilize checklists for engineering when evaluating and how to forward calls to a colleague or complex tasks that require multiple redesigning care processes and voice mail when they are performing steps or are known to be distraction- workspaces in order to decrease the a procedure, show staff how to save prone24 (e.g., central-line insertion, potential for distraction7,32 (e.g., documentation in the computer sys- ventilator-associated pneumonia pre- conduct observations of processes tem so that it can be resumed after vention measures, continuous renal known to be distraction-prone the distraction is addressed). replacement therapy). in order to identify sources of — Consider offering a course in mind- — Implement communication strategies distraction and develop a plan to fulness meditation for clinical staff.25,26 that do not involve oral communica- minimize them, redesign medication — Avoid communication of irrelevant tion,10 especially in busy clinical areas preparation areas to limit outside information whenever possible, but with high noise levels (e.g., outline distractions). especially when performing tasks a protocol for sending and respond- ing to text messages in facilities that CONCLUSION with high cognitive loads13,27,30 (e.g., avoid small talk when performing provide text-pagers or smartphones Distractions are encountered in health- safety-critical tasks such as the preop- to clinical staff). care settings on a nearly continuous basis. erative time-out or programming an — Use written reminders as event-based These distractions originate internally and cues to complete future tasks. Ensure externally to clinicians. There are many Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 7 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S and varied stimuli that divert attention must be processed, resulting in high time. But in many more cases, efficiency away from primary tasks. With each new intrinsic and extraneous cognitive loads. is decreased because of the limited ability technology introduced to the healthcare Under these circumstances, distrac- of the human brain to process more than setting, new sources of distraction are rec- tion can be particularly detrimental to one task at the same time. ognized. The relatively recent addition of performance. Clinicians can take steps to reduce the computerized health information systems, Most of the patient safety event reports impact of distraction by recognizing com- cell phones, and smartphones has brought to the Authority that were attributed to mon sources of distraction and situations new attention to the study of distraction distraction by reporters involved medica- that are distraction-prone, identifying and its impact on patient safety. tion errors or errors related to proce- clinical tasks or procedures that are most The work of clinicians places high demands dures, treatments, or tests. Multitasking likely to result in medical error and patient on working memory. This is due to the is frequently the culprit in these patient harm as a result of distraction, and apply- high complexity and large amounts of safety events. In some cases, multitasking ing specific risk reduction strategies. continuously changing information that increases efficiency by eliminating down- NOTES 1. 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NY Times 2011 Dec 14 [cited 2012 Nov 20]. http:// Page 8 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority 24. Gawande A. The checklist [online]. in meditation. Trends Cogn Sci 2008 30. Pape TM, Guerra DM, Muzquiz M, New Yorker 2007 Dec 10 [cited 2012 April;12(4):163-9. et al. Innovative approaches to reducing Nov 19]. http://www.newyorker.com/ 27. Lewis TP, Smith CB, Williams-Jones P. nurses’ distractions during medication reporting/2007/12/10/071210fa_fact_ Tips to reduce dangerous interruptions administration. J Contin Educ Nurs gawande. by healthcare staff. Nursing 2012 Nov; 2005 May-Jun;36(3):108-16. 25. van Vugt MK, Jha AP. Investigating 42(11):65-7. 31. Jones SW. Reducing medication admin- the impact of mindfulness meditation 28. Waring JJ. Constructing and re-con- istration errors in nursing practice. training on working memory: a mathe- structing narratives of patient safety. Soc Nurs Stand 2009 Aug;23(50):40-6. matical modeling approach. Cogn Affect Sci Med 2009 Dec;69(12):1722-31. 32. Norris B. Human factors and safe Behav Neuroci 2011 Sep;11(3):344-53. 29. Cox LM, Logio LS. Patient safety patient care. J Nurs Manag 2009 26. Lutz A, Slagter HA, Dunne JD, et al. stories: a project utilizing narratives Mar;17(2):203-11. Attention regulation and monitoring in resident training. Acad Med 2011 Nov;86(11):1473-8. LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Assess sources of distraction present The following questions about this article may be useful for internal education and in healthcare settings and the means assessment. You may use the following examples or develop your own questions. by which they can lead to error. 1. Assess the following scenarios and determine which one describes an interruption — Recall the predominant safety event during information encoding? types associated with distraction, a. A physician is completing placement of a nasoduodenal feeding tube in a according to reports submitted to patient and is interrupted by a medical student asking a question about a pre- the Pennsylvania Patient Safety scription missing from the discharge instructions for another patient who is Authority. leaving the hospital. The physician forgets to order the x-ray to confirm place- — Distinguish between interruptions ment of the feeding tube. that convey greater potential to dis- b. A nurse is receiving critical blood gas results over the phone from the labora- rupt performance of the primary task tory during a patient emergency situation. While writing down the results, the and those that convey less potential anesthesiologist asks the nurse to bring the respiratory emergency equipment to disrupt performance of the pri- box with her when she comes back to the room. When reading the blood gas mary task. results to the emergency response team, she discovers she did not write down — Identify strategies for decreasing the the bicarbonate level. potential for distraction and harm. c. A pharmacy technician is about to restock an automated dispensing cabinet with HYDROcodone. A nurse interrupts to ask if the technician has brought the HYDROmorphone that had been ordered from the pharmacy 30 minutes ago for a patient in severe pain. The technician checks the stock of HYDRO- morphone, finds the drawer empty, and tells the nurse to call back down to the main pharmacy. The technician proceeds to place the HYDROcodone tablets in the HYDROmorphone drawer. d. A patient asks the nutrition hostess for extra sugar and ketchup. On the way to the kitchenette, another patient stops the hostess and asks for their lunch to be reheated. The hostess takes the tray to the kitchenette, and when she arrives, she grabs some salt and pepper and ketchup packets to take back to the first patient. 2. Which of the following event types associated with distraction were reported most frequently to the Authority from 2010 through 2011? a. Medication error: dose omission b. Medication error: overdosage c. Medication error: wrong patient d. Medication error: unauthorized drug Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 9 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S SELF-ASSESSMENT QUESTIONS (CONTINUED) A nursing assistant set an alarm on her watch to remind her to return to a patient’s room to perform a repeat fingerstick blood sugar test. When the alarm sounded half an hour later, she was unable to recall which patient needed the fingerstick. 3. The nursing assistant was using the alarm to support prospective memory, or remembering to do something in the future. The alarm failed to achieve its desired result in this instance because of which of the following? a. The alarm provided a time-based cue that did not offer information about what was to be done. b. The use of alarms to aid prospective memory has been found ineffective in multitasking environments, such as hospitals. c. The alarm provided an event-based cue that did not offer information about what was to be done. d. The nursing assistant was suffering from alarm fatigue. 4. Each of the following statements regarding interruptions are true except: a. Interruptions similar to the primary task are more disruptive than interrup- tions that are dissimilar. b. Interruptions during task performance by novice practitioners are more disrup- tive than interruptions during task performance by experienced practitioners. c. Interruptions occurring during performance of tasks requiring high working memory load are more disruptive than interruptions occurring during tasks requiring low working memory load. d. Interruptions presenting through a different modality than the primary task (e.g., auditory versus visual) are more disruptive than interruptions presenting through the same modality. 5. All of the following statements regarding multitasking are false except: a. Multitasking can increase efficiency for healthcare professionals by eliminating downtime. b. Multitasking is not a highly valued skill for healthcare professionals. c. Multitasking is only a contributor to errors in high-acuity care areas, such as critical care areas and the operating room. d. There is no limit to the human brain’s ability to multitask, given enough simu- lation training. 6. All of the following are risk reduction strategies that a hospital can use to decrease the potential for distraction and harm except: a. Move the automated medication dispensing cabinet and medication carts to an area away from high traffic flow and clinical alarms, preferably behind closed doors. b. Implement a strict no “small talk” policy for all staff working in clinical areas, except during meal breaks. c. Have novice staff practice clinical tasks in a simulation lab setting using sce- narios designed to include multiple interruptions. d. Require staff to forward all calls to another staff member when entering a patient room to perform an invasive procedure. Page 10 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 1—March 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. 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