Article Text

Download PDFPDF

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study
  1. Johanna I Westbrook1,
  2. Magdalena Z Raban1,
  3. Scott R Walter1,
  4. Heather Douglas2
  1. 1 Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
  2. 2 School of Psychology and Exercise Science, Murdoch University, Singapore, Singapore
  1. Correspondence to Professor Johanna I Westbrook, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia; Johanna.westbrook{at}


Background Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals’ task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied.

Objective To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors.

Methods 36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians’ working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep.

Results Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.

Conclusion Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments.

  • medication safety
  • communication
  • emergency department
  • human factors
  • interruptions

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors All authors contributed to the development of the detailed study methods and protocol. SRW and MR collected the observational data. HD administered the psychometric tests. MR led the classification and analysis of the prescribing error data. SRW designed and led the statistical modelling. JIW conceived of the study and obtained funding, prepared the manuscript and all authors contributed to the interpretation of results, revisions to the paper and final approval of the manuscript.

  • Funding This study was funded by National Health and Medical Research Council (1054146) and an Australian Research Council Discovery grant (DP160100943).

  • Competing interests None declared.

  • Ethics approval South Eastern Sydney Local Health District Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This article has been updated since publication as minor typographical errors were missed during proofing.