Review
Interruptions in healthcare: Theoretical views

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Abstract

Background

Researchers in healthcare have begun to investigate interruptions extensively, given evidence for the adverse effects of work interruptions in other domains and given the highly interruptive hospital environment. In this paper, we reviewed literature on interruptions in critical care and medication dispensing settings in search of evidence for a relationship between interruptions and adverse events.

Methods

The literature search included the databases MEDLINE, CINAHL + Pre CINHAL, Health Sources: Nursing Academic Edition, EMBASE, PsycINFO, ISI Web of Science and Ergonomics Abstracts. The paper titles and abstracts were subsequently reviewed. After the initial search, we reviewed paper titles and abstracts to define the subset for review.

Results

We currently lack evidence in healthcare of the extent to which interruptions lead to adverse effects. The lack of evidence may be due to the descriptive rather than causal nature of most studies, the lack of theory motivating investigations of the relationship, the fact that healthcare is a complex and varied domain, and inadequate conceptualizations of accident aetiology. We identify two recent accident theories in which the relationship between activity and medical errors is complex, indicating that even when it is sought, causal evidence is hard to find.

Discussion

Future research on interruptions in healthcare settings should focus on the following. First, prospective memory research and distributed cognition can provide a theoretical background for understanding the impact of interruptions and so could provide guidance for future empirical research on interruptions and the planning of actions in healthcare. Second, studying how interruptions are successfully rather than unsuccessfully overcome may better help us understand their effects. Third, because interruptions almost always have positive and adverse effects, more appropriate dependent variables could be chosen.

Introduction

There are many aspects of healthcare working conditions that, if changed, could reduce the incidence of medical errors. In 2003 the Agency for Healthcare Research and Quality (AHRQ) published an evidence report which states that reducing interruptions and distractions will probably reduce the number of medical errors [1]. However, the AHRQ's conclusion is based on evidence from aviation [2] and from a study on medication dispensing errors [3]. The AHRQ authors add that the “evidence of the association between interruptions and distractions and errors in other areas of medicine is insufficient” [1, p. 34].

Given that medical staff are interrupted frequently [4], [5], [6], given that interruptions disrupt human cognition [7], [8], and given the evidence from other domains [2], it may be that the research approaches chosen are inappropriate rather than that there is no relation between interruptions and medical errors. Therefore, it is more likely that there is absence of evidence than evidence of absence [9], [10] for an effect of interruptions on medical errors.

In Section 2, we summarize recent studies on interruptions and distractions in critical care areas and medication dispensing. We conclude that (1) evidence for a relation between interruptions and medical errors is still weak, probably more because of methodological approaches than because there is evidence that the relation is absent, (2) different definitions of interruptions are used by different researchers, making it hard to compare studies, (3) the papers reviewed lack theoretical background that could be useful when investigating interruptions, and (4) generalizations from the aviation to the medical domain may not always be appropriate.

In Section 3, first we discuss prospective memory, which is the ability to recall a previously formed intention at a specific time or cue in the future without being encouraged to do so [11]. Second, because 21 out of the 35 papers reviewed consider memory failures to be a direct result of interruptions, we use prospective memory as theoretical background to interpret the effects of interruptions. Third, we discuss differences and similarities between the medical and aviation domain that influence the effect of interruptions on memory. The section ends with implications of prospective memory for information technology (IT) systems.

In Section 4, we address the role of interruptions in adverse events. First, we contrast the evidence-based approach in the papers reviewed with Reason's Swiss cheese model [12] and Hollnagel's systemic accident model [13]. We conclude that the accident models capture the complex nature of interruptions better. Second, in line with Hollnagel's systemic accident model [13], we suggest that observing how people overcome interruptions could offer new insights into the processes affected by interruptions. Third, we argue that interruptions are not generally “bad” or “good”. To understand the effects of interruptions, researchers need to choose appropriate dependent variables. The final part of the section addresses implications of the systemic accident model for healthcare informatics.

Section snippets

Review on interruptions in the medical domain

We undertook a broad review of recent papers published on interruptions in the medical domain. The AHRQ report covers the period up to 2002, so our search was restricted to papers in English written after 2002. An initial search was conducted in the databases MEDLINE, CINAHL + Pre CINHAL, Health Sources: Nursing Academic Edition, EMBASE, PsycINFO, ISI Web of Science and Ergonomics Abstracts. We conducted two separate searches. The first search was done to retrieve healthcare papers on

Interruptions and memory

In this section, first we discuss prospective memory (PM) theories and point out the general use and need for research on PM in healthcare. Second, we discuss a model by Parker and Coiera [48] who explain PM failures by limited working memory resources. We show that PM is a useful theory to investigate interruptions. Third, we indicate differences between the medical and the aviation domains that might influence the effect of interruptions on PM.

Logical connection of interruptions to incidents

As the literature review shows, interruptions do not always lead to adverse events—indeed, they do so very seldom. If we are to make a connection between interruptions and adverse events, we need to take into account current thinking about how adverse events occur.

In the last 25 years, accident models have shifted from “one cause leads to one effect” models to models that assume that accidents have multiple causes. In contrast, the evidence-based approach underlying the AHRQ report [1] and many

Conclusions

The AHRQ report of 2003 [1] rated the evidence as insufficient that interruptions and distractions jeopardize patient safety in healthcare domains other than medication dispensing errors. Five years later, solid evidence is absent. The descriptive studies do not relate interruptions to medical error in any way, which constitutes absence of evidence. Three cause-and-effect studies provide evidence of a connection between interruptions and error (evidence of presence); one study provides evidence

Acknowledgments

This paper was written while Tobias Grundgeiger was holding an Endeavour IPRS at The University of Queensland. This project is supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Patient Safety. The Centre is funded by the Australian Council for Safety and Quality in Health Care (the Safety and Quality Council) and is designated as a NHMRC Centre of Research Excellence. The Safety and Quality Council is a joint initiative of the Australian,

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