Operational failures and interruptions in hospital nursing

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

In addition to these fail-safe techniques that minimize the negative impact of interruptions, other strategies can be used to prevent interruptions. The Institute of Medicine report, Keeping Patients Safe (2004), recommends reducing interruptions nurses encounter during medication preparation by creating a visual signal (e.g., a hat or apron with the words, "Please don't interrupt-preparing medications") that alerts other nurses and patients' families that the nurse should not be interrupted. The report also recommends further reduction of interruptions by filtering messages through a secretary or by providing nurses with enough information to triage their messages, distinguishing between those that need immediate attention and those that can wait to be inserted in the nurse's work so as not to cause disruption (Speier et al. 1999; Page 2004). Similar suggestions have been developed for other professionals, such as engineers (Perlow 1999) and pharmacists (Flynn et al. 1999).

Focus on Improving Work System Performance

In contrast to managing unavoidable uses of the three tactics, strategies for reducing avoidable instances focus on improving work systems. For example, an initiative within the University of Pittsburgh Medical Center (UPMC) system, addressed the repetitive problem of not being able to quickly locate the appropriate keys when narcotics had to be dispensed. The nurses figured out how to allow each nurse to carry a key during the shift while still maintaining security. The cost of the solution was minimal and the savings was estimated to be approximately 2,900 nursing hours per year in the 350-bed institution. Another hospital within the UPMC system targeted medication administration as a process for improvement. A series of quick, low-cost redesigns of pharmacy work reduced inventory stock-outs by 85 percent, reduced the overall size of the inventory, and reduced the time required to fill orders (Thompson, Wolf, and Spear 2003). The point of these examples is not to suggest that the solutions developed at UPMC should be copied; their formulation may be quite site-specific. However, the improvement process employed by UPMC--treating individual operational failures as triggers for process improvement, rather than having health care workers repeatedly work around disruptions--may have some wider benefit.

CONCLUSIONS

This study provides a detailed picture of nursing work, filling an important gap in the literature on the health care work environment. Others have commented on health care's adaptive nature; however, the tactics of partitioning, interweaving, and reprioritization used to achieve flexibility have not been explicitly expressed. Therefore, identifying and defining these tactics bring additional clarity to nursing work--and possibly to other work done in similar conditions, such as the work of physicians and other health care providers. In addition, our observations of the tactics, when combined with existing literature on the effects of delays, distractions, and interruptions on work, suggest that these tactics raise the likelihood of human error, and therefore of harm to patients. Ironically, at the same time, nurses' actions can prevent human error, improve patient outcomes (e.g., Aiken et al. 2002; Kovner et al. 2002), and improve work systems (e.g., Thompson, Wolf, and Spear, 2003; Tucker and Edmondson, 2003). Therefore, understanding which responses improve patient care and which impede care could provide a valuable framework for practitioners and educators.