By Charles A. Pilcher MD FACEP
November, 2014
Last February in Emergency Physicians Monthly Dr. Jeremy Tucker wrote a column titled “The No-Interruption Zone.” Dr. Tucker, a busy ED physician at MEP/St. Mary’s Hospital in Leonardtown, Maryland, talked about the effects of physician interruptions on patient flow and safety, and the ways in which interruptions lead to errors in patient care. The problem is serious, with interruptions reported to occur over 6 times per hour in one study. Typically, this leads to problems with returning to – or recalling – the task at hand, resulting in real or potential safety issues.
Almost every malpractice case contains at least one element that can be attributed to an interruption or lack of focus.
While the aviation industry has strict policies on pilot interruptions during critical aspects of flight, no such policies exist in the ER. Most departments are a beehive of activity similar to an aircraft on approach to landing. This makes it absolutely critical that a physician have “time to think” in order to properly process his or her findings for the benefit – and safety – of the patient. “While entirely eliminating interruptions in the ED isn’t realistic, how much interruption is OK?” asks Dr. Tucker.
To reduce the chance of error, he lists several areas where interruptions, distractions and disruptions should be limited or eliminated altogether.
- The exam room. During an H & P, interruptions lead to a loss of focus, as it is during this time that the physician is formulating a differential diagnosis and evaluation plan. Dr. Tucker suggests that the exam room should be a “No Interruption Zone” (NIZ). Hold phone calls and have others make note of the point of interruption if an emergency arises.
- CPOE. When ordering tests and treatments, accuracy is crucial. This should also be a NIZ. Nurses already do this when managing medications, and it is equally important for physicians any meds or tests are ordered.
- Results Review. When test results return, interruption at this point can result in serious oversight with regard to significant findings.
- Procedures. As with aviation, checklists have helped make procedures safer. Breaks in procedure resulting from interruptions, put those safety gains at risk.
- Sign-Out/Handoff. Change of shift is another critical task requiring attention to detail, and where interruptions are limited. Nurses have used “Report” in this fashion for decades (occasionally, it seems, using an NIZ approach to avoid accepting a new patient from the ED.) Checklists also work here to make sure all important information has been transferred to the oncoming provider,” notes Dr. Tucker. Handoffs have been previously covered in the May and June 2013 issues of this Bulletin.
- Alarm Fatigue. This was covered in last month’s “Perspective.” Whether it’s ringing phones, computer alerts, or a monitor alarm, each one is a likely interruption. The ER is busy enough without unnecessary alarms; they should be reduced to the lowest safe level.
X-Ray procedure rooms, radiation therapy suites, and even some medication stations have lights that indicate that the room is active, i.e., “Don’t enter,” or “Don’t Interrupt.” A similar approach could be used for Dr. Tucker’s “NIZ,” i.e. a small LED on the computer or outside the room that indicates an activity in progress that should not be interrupted. Dr. Tucker suggests a combination of other approaches to address the problem, including staff education, department policies, IT solutions, and changes in the design or layout of the space.
While interruptions are part of the ED culture, the high-energy of which actually attracts physicians to the specialty, they must be controlled and appropriate to assure patient safety. Where interruptions cannot be avoided, recognizing the critical times and situations where interruptions are most dangerous, and addressing them to the extent possible, can improve the quality of care provided.
And this is true in physicians’ offices and other less hectic environments as well.