Interruptions Increase Errors. Really?

              

Nurse's Note artist: JParadisi. pencil and ink on paper

     I am writing this post while my husband pumps air into his bicycle tires in our living room (ka-chunka chunka-chunka), muttering about how much work cycling is. Finding uninterrupted time to write or paint is sometimes challenging. In nursing, where the safety of patients depends on accuracy, it is impossible. It is the biggest absurdity of my two careers.    

      This morning I read a Medscape article about interruptions exponentially increasing nursing medication and procedure errors. Researchers collected data for the study by observing nurses at two hospitals. Although the conclusion seems obvious, I appreciate hard numbers applied to a reality all nurses recognize. Collecting data is the first step towards change. Shockingly, according to the study a single interruption during medication administration increases frequency of errors to 25%.    

     In all my years of nursing, I have never completed a single task from start to finish without an interruption. A coworker asks a question, a patient or family member needs something, a phone call from a physician or another department and I am distracted. Once, on pediatric unit, I entered my first patient’s room to find him vomiting violently in the bathroom. While holding his small head out of the toilet, calming him down, and keeping his IV in place, my pager beeped. I had to ignore it, but as soon as the patient was safely in bed, I went to the nurses’ station to see why I was paged. There, a unit secretary lectured me about her expectation for an immediate call back to a page (although doctors have an unwritten, twenty-minute grace period to answer pages for non-urgent matters). Why was I paged? A doctor had a question. I did not need to explain myself to the secretary; when I did, her expectation remained unchanged. Whatever. I called the doctor back, and there wasn’t a problem. My point is interruptions can wait until a patient is safe. The problem is most nursing units have expectations that everything be done now. STAT is the most over-used word in health care. Is there really such a thing as STAT Colace? There is an unrealistic pressure on nurses to do everything at once. It is impossible, and patient safety suffers. It’s a no brainer. How sad studies are necessary to prove the obvious.    

        Creating a safe zone where nurses can draw up medications without interruption is a reasonable idea; however, it does not address the interruptions occurring in the patient’s room, like the pager going off in my pocket.  I am often interrupted while double-checking blood, accessing a port, or hanging chemo by the patient asking for a blanket “when you get a chance” or answering their cell phone. They do not realize how much concentration it takes to give safe care. More than once, I have explained to patients or family members “I need to focus on what I’m doing to keep you safe, and I will be glad to answer your question as soon as I finish.”  I’ve never had a patient or family member complain about it. They appreciate dedication to their safety.   

     Interruptions are a daily part of everyone’s life. Reducing nonessential ones is crucial to safe nursing practice, and adjusting expectations (including staffing ratios) is critical.     

     You can find the article   

Interruptions Linked to Medication Errors by Nurses    

At  medscape.com

The Woman from Human Resources is Right About This

An Unexpected Discovery photo: JParadisi 2009

     A friend of mine told me about his experience a few weeks ago at a dental appointment. He arrived on time for a scheduled cleaning with his hygienist. After waiting five minutes, the hygienist came to the door of the waiting room. My friend stood up to follow her, but the hygienist called the name of a woman sitting across the room instead. My friend sat back down. Puzzled, he assumed the hygienist would return for him shortly.  My friend works in health care. The doctor’s office he works for sometimes runs late, and patients wait. He figured it was Karma.  After staring mindlessly at the pages of a six month old tabloid magazine, he checked his cellphone for messages and noticed  half an hour had passed. He requested a day off from work for this weekday appointment. Anticipating it to last an hour he scheduled other appointments and mundane errands after the routine dental cleaning. He wasn’t going to finish his errands that day.     

     Finally, a dental technician called his name. Once he was in the exam chair, the technician told him the appointment changed. He was rescheduled for an exam with the dentist instead of the hygienist. The technician readied to take a full mouth of x-rays.  My friend asked about the cleaning  he  scheduled the appointment for, and the tech told him not to worry about it.  He told the tech that  he only had time for a teeth cleaning, and this was his priority for the appointment. Could he reschedule the exam with the dentist for a later date? Annoyance reverberated throughout the dental office like an earthquake measuring 8.8 on the Richter scale. Eventually his teeth were cleaned. The appointment lasted two hours. My friend left puzzled by the entire scenario. Weeks before this appointment, the office called him twice with reminders that he needed to call within 24 hours to avoid an office charge if he wasn’t there.  Why was his appointment changed without his permission, my friend asked?  Why wasn’t he at least informed a change was necessary with one of those phone calls?     

     There are lessons to extrapolate from my friend’s story into my nursing practice.  Occasionally my patients wait beyond their scheduled appointment times too.  Events occur or sometimes patients are late, causing unexpected delays. More intriguing is the chasm between the expectations of my friend and his dentist, leading to an unhappy encounter for each. I imagine that the dentist and my friend both felt disrespected.     

     How many times do patients say, “I didn’t realize this was going to take so long”? Immediately, we have different expectations for the appointment. I don’t remember any patient expecting a different treatment than the one I expected to administer though.     

     The story reminds me of how important communication is when managing expectations for both the patient and the care provider.  Unexpected changes without explanation during a medical (or dental) appointment are rarely appreciated.  The Human Resources woman is right about this:  managing expectations is an important factor in customer service and satisfaction.