Operational failures and interruptions in hospital nursing

Health Services Research, June, 2006 by Anita L. Tucker, Steven J. Spear

   It takes time when you have to repeat something, or look at
   something again, or follow through on something that didn't happen.
   That takes away a lot of time from patient care. Just the fact of
   calling to the desk, interrupting the secretary, hunting something
   down, wondering why something is taking so long, that takes time.
   You can literally be pulled in four of five different directions
   all at once. Just to keep track of things and to spend all that
   time trying to get a task done that would have been pretty simple.
   It can turn into a nightmare actually.

DISCUSSION

Our study suggests two avenues for improving the nursing work environment. First, our analysis showed that conditions inherent to meeting patient needs make 95 percent of the interweaving and reprioritization unavoidable. Thus, together with nursing management, nurses should try to design nursing processes that minimize negative impacts of interruption. We provide more details in the section below. However, 5 percent of the interruptions stemmed from operational failures, and therefore removing known problems could help prevent avoidable interruptions. System improvement can be accomplished by using failure occurrence to trigger removal of underlying causes, rather than the common approach of relying on people to work around failures (Tucker, Edmondson, and Spear 2002; Spear and Schmidhofer 2005).

When the Tactics Cannot Be Avoided

We recognize that a necessary first step in patient safety is ensuring appropriate patient loads and enabling nurses to exercise control over their practice. Provided that these conditions exist, work system designs can help prevent errors through mistake proofing, which can reduce the negative impact of interruptions. Other industries, such as nuclear power, civil aviation, and aircraft carrier operations, have created mechanisms to help ensure reliable and error-free performance (Weick and Roberts 1993; Weick, Sutcliffe, and Obstfeld 1999). Some health care organizations have been successful in adopting techniques, such as check lists, which are visual management tools that show what work has been performed and what work remains to be performed (Hirano and Talbot 1995). For example, at Johns Hopkins Hospital, an interdisciplinary critical care quality improvement team developed a checklist of best practices for reducing bloodstream infections from central venous catheters (CVC). This checklist was used during insertion and helped ensure that all the steps were properly performed, resulting in elimination of almost all CVC-related bloodstream infections (Berenholtz et al. 2004).

Human factors engineering can also be incorporated into the design of the physical space to make it more difficult for people to commit errors, even if they are interrupted and their chain of thought is broken (Billings 1984; Gosbee 2002, 2004; Grout 2003). For example, in response to medical accidents, anesthesia machines have been redesigned to help prevent inadvertently turning off the flow of oxygen to the patient (Wiklund 2002) or hooking up nitrous oxide instead of oxygen (Ko 2005). These solutions do not add any additional steps in completing work, but make it more difficult to inadvertently make a dangerous mistake (Grout 2003).