Reducing Interruptions and Saving Lives: New Study on Drug Treatment Errors

I have written here and other places on Amy Edmondson's wonderful research on how, when nurses feel as if they have psychological safety, they openly talk about and try to correct drug treatment errors, but when they work in a climate of fear, they are afraid to even admit when they have made mistakes -- which led to a rather bizarre finding in Amy's early research that in nursing units where people felt safe, even compelled,to talk about and learn from mistakes, they reported ten times more errors than in a nursing unit where the supervisor slammed nurses who admitted or where "caught" making mistakes. 

This morning's San Francisco Chronicle reports an equally fascinating study on reducing drug treatment errors. This one focuses on the evils of interruptions, which as  research by Gloria Mark shows, slows and undermines performance, and creates great job stress. As the article reports "A UCSF program to improve accuracy in administering drugs - with particular emphasis on reducing interruptions that often lead to mistakes - resulted in a nearly 88 percent drop in errors over 36 months at the nine Bay Area hospitals, according to results being released today."  The cool thing about the article is that the nurses at different hospitals invented different local methods for reducing interruptions, to the vest you see pictured above to covering windows so colleagues couldn't see them (and thus run in and interrupt them), to developing quiet zones, or quiet times during drug administration.  Note that drug treatment errors are huge problem, resulting in over 400,000 preventable injuries per year and 3.5 billion in costs. So a 88% reduction is huge.

This research is also fascinating to me because it shows how, so often, when people say they are too busy, don't have enough money, or their will be resistance to change that these are excuses, or worse yet, negative self-fulfilling prophecies.  In particular, I think that people -- especially managers -- often use spending money as a substitute for thinking, when inexpensive and low-tech solutions work just fine.  I am looking forward to digging into this research further.

Comments

[metacool]

I need a vest like that...

[Jim]

Thanks for sharing this article. OF course we're all in favor of reducing errors in medical care and the differences amongst nurses and the conditions in which they work and their quality of management is fascinating.
And what about MD's? Seems like there's very little written about differences within this profession and the effect on our medical care.

[jeffrrogers.wordpress.com]

Interrupts are a common occurrence in the work environment. We are pulled every which way throughout the day... a meeting here, a meeting there. Next, emails and instant messages bombard us, not to even mention phone calls. How can any of us ever get any work done? I love the idea of the "do not interrupt" vest. I think we'd all be more efficient if we'd just disconnect ourselves from the world for a few hours a day!

I just read Jonatahn Friesen's comment... good stuff there!

[working girl]

Where can I get one of those jackets???

[Randy Bosch]

Excellent information, applicable to all disciplines and professions, though often not as critical as healthcare.

Please note, however, that the practice of covering windows - windows usually installed in just the past decade or so - most probably violates several State and Federal regulations intended to prevent various "personnel problems" in Pharmacies and hospital Medicine Rooms, and should not be forwarded as a way to prevent interruptions without careful review of regulations.

[Jonathan Friesen]

John Medina, author of Brain Rules, and developmental molecular biologist, summarizes the research on the brain's ability to multitask with this: "Multitasking, when it comes to paying attention, is a myth...We are biologically incapable of processing attention-rich inputs simultaneously."

Medina describes the brain's function in a similar fashion to the way a single processor computer works: it uses "task-switching." When attempting to multitask, your brain must disengage from the current task, re-engage the new one, disengage the new one, and re-engage the old one while trying to remember where it was at before disengaging. Medina notes that various studies show this task-switching process to be very inefficient--not only does it take around 50% longer to complete a task, that person makes up to 50% more errors performing the task (Medina, Brain Rules, pp 84-87).

The information that is the Chronicle article certainly reinforces this notion.