Quality

Workflow Interruptions Threaten Patient Safety, Hospitalists' Job Satisfaction


 

Interruption Homicide Dr. Whitcomb

Figure 1. Error percentages for no-switching and switching activities1

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.1 The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).1 These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Error percentages for no-switching and switching activities Dr. Whitcomb

Figure 1. Error percentages for no-switching and switching activities1

Effects of alcohol vs. cell phone use on mean reaction times Dr. Whitcomb

Figure 2. Effects of alcohol vs. cell phone use on mean reaction times2

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.2

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

  • Having unit-based hospitalist staffing;
  • Holding multidisciplinary rounds;
  • Training nurses to batch pages;
  • Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
  • Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.


Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

References

  1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
  2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

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