ReviewInterruptions in healthcare: Theoretical views
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,
References (93)
- et al.
Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices
Ann. Emerg. Med.
(2001) - et al.
Interruptive communication patterns in the intensive care unit ward round
Int. J. Med. Inf.
(2005) - et al.
Communication patterns in a UK emergency department
Ann. Emerg. Med.
(2007) - et al.
Towards a hybrid method to categorize interruptions and activities in healthcare
Int. J. Med. Inf.
(2007) - et al.
Interruptions in a level one trauma center: a case study
Int. J. Med. Inf.
(2008) - et al.
Emergency department communication links and patterns
Ann. Emerg. Med.
(2007) - et al.
Variation in communication loads on clinical staff in the emergency department
Ann. Emerg. Med.
(2004) - et al.
Emergency physicians’ behaviors and workload in the presence of an electronic whiteboard
Int. J. Med. Inf.
(2005) - et al.
The prevalence and nature of errors and near errors reported by hospital staff nurses
Appl. Nurs. Res.
(2004) - et al.
Drug-dispensing errors in the hospital pharmacy
Clinics
(2007)