Interruptions in the wild: Development of a sociotechnical systems model of interruptions in the emergency department through a systematic review

Attention Among Health Care Professionals : A Scoping Review

BACKGROUND

The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors.

PURPOSE

To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts.

DATA SOURCES

Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024.

STUDY SELECTION

English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction.

DATA EXTRACTION

Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used.

DATA SYNTHESIS

Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention.

LIMITATIONS

Does not synthesize answers to specific questions. Quality of studies was not assessed.

CONCLUSION

This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention.

PRIMARY FUNDING SOURCE

None.

Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach

BACKGROUND

Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models.

METHODS

The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached.

RESULTS

The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions.

CONCLUSION

This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.

More isn't always better: Technology in the intensive care unit

BACKGROUND

Clinical care in modern intensive care units (ICUs) combines multidisciplinary expertise and a complex array of technologies. These technologies have clearly advanced the ability of clinicians to do more for patients, yet so much equipment also presents the possibility for cognitive overload.

PURPOSE

The aim of this study was to investigate clinicians' experiences with and perceptions of technology in ICUs.

METHODOLOGY/APPROACH

We analyzed qualitative data from 30 interviews with ICU clinicians and frontline managers within four ICUs.

RESULTS

Our interviews identified three main challenges associated with technology in the ICU: (a) too many technologies and too much data; (b) inconsistent and inaccurate technologies; and (c) not enough integration among technologies, alignment with clinical workflows, and support for clinician identities. To address these challenges, interviewees highlighted mitigation strategies to address both social and technical systems and to achieve joint optimization.

CONCLUSION

When new technologies are added to the ICU, they have potential both to improve and to disrupt patient care. To successfully implement technologies in the ICU, clinicians' perspectives are crucial. Understanding clinicians' perspectives can help limit the disruptive effects of new technologies, so clinicians can focus their time and attention on providing care to patients.

PRACTICE IMPLICATIONS

As technology and data continue to play an increasingly important role in ICU care, everyone involved in the design, development, approval, implementation, and use of technology should work together to apply a sociotechnical systems approach to reduce possible negative effects on clinical care for critically ill patients.

The Standardization of the Emergency Department Response to Chemical, Biological, Radiological, and Nuclear (CBRN) Events: Human Factors/Ergonomics Approach

OBJECTIVE

To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done.

METHODS

Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England.

RESULTS

Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis.

CONCLUSION

The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

Interruption science as a research field: Towards a taxonomy of interruptions as a foundation for the field

Interruptions have become ubiquitous in both our personal and professional lives. Accordingly, research on interruptions has also increased steadily over time, and research published in various scientific disciplines has produced different perspectives, fundamental ideas, and conceptualizations of interruptions. However, the current state of research hampers a comprehensive overview of the concept of interruption, predominantly due to the fragmented nature of the existing literature. Reflecting on its genesis in the 1920s and the longstanding research on interruptions, along with recent technological, behavioral, and organizational developments, this paper provides a comprehensive interdisciplinary overview of the various attributes of an interruption, which facilitates the establishment of interruption science as an interdisciplinary research field in the scientific landscape. To obtain an overview of the different interruption attributes, we conducted a systematic literature review with the goal of classifying interruptions. The outcome of our research process is a taxonomy of interruptions, constituting an important foundation for the field. Based on the taxonomy, we also present possible avenues for future research.

Measuring Potential Visual Exposure of Physicians During Shift-End Handoffs and Its Impact on Interruptions, Privacy, and Collaboration

BACKGROUND

Frequent interruptions, inadequate privacy, and lack of collaboration are barriers to safe and efficient end-of-shift handoffs between emergency physicians. Varying levels of visibility to and from physicians can impact these outcomes. This study quantifies potential visual exposure of physicians in workstations with varying enclosure levels using isovist connectivity (IC) as a measure. Further, this study examines the association of IC with number of interruptions/hour, perceived collaboration, and privacy during handoffs.

METHODS

In-person observations were conducted during 60 handoffs to capture interruptions. Surveys were administered to the incoming and outgoing physicians to garner their perceptions of the extent of interruptions, collaboration, and privacy. Spatial analysis was conducted using DepthmapX.

RESULTS

Findings demonstrate significant differences in IC scores based on (a) physicians location within the workstation during; (b) handoff approach (individual or collaborative); (c) position during handoff (sitting or standing). Documented interruptions were highest in the high IC locations and lowest in the medium and low IC locations. Physicians in low IC locations perceived to have sufficient privacy to conduct handoffs.

LIMITATIONS AND CONCLUSION

It should be noted that the three pods, each housing a physician workstation with different enclosure levels, varied in number of patient rooms, patient acuity, overall size, and the location of workstations. While contextual variables were considered to the extent possible, several other factors could have resulted in differences in number of interruptions and collaboration levels. This study provides design recommendations for handoff locations and a method to test emergency physician workstation designs prior to construction.

Explaining emergency physicians' capacity to recover from interruptions

OBJECTIVE

To assess whether the capacity to utilize cues amongst emergency physicians is associated with differences in the capacity to recover performance following an interruption.

BACKGROUND

Interruptions are implicated in errors in emergency medicine due to the cognitive load that they impose on working memory, resulting in a loss of performance on the primary task. The utilization of cues is associated with a reduction in cognitive load during the performance of a task, thereby enabling the allocation of residual resources that mitigates the loss of performance following interruptions.

METHOD

Thirty-nine emergency physicians, recruited at a medical conference, completed an assessment of cue utilization (EXPERTise 2.0) and an online simulation (Septris) that involved the management of patients presenting with sepsis. During the simulation, physicians were interrupted and asked to check a medication order. Task performance was assessed using scores on Septris, with points awarded for the accurate management of patients.

RESULTS

Emergency physicians with higher cue utilization recorded significantly higher scores on the simulation task following the interruption, compared to physicians with lower cue utilization (p = .028).

CONCLUSION

The results confirm a relationship between cue utilization and the recovery of performance following an interruption. This is likely due to the advantages afforded by associated reductions in cognitive load.

APPLICATION

Assessments of cue utilization may assist in the development of interventions to support clinicians in interruptive environments.

Operating room team strategies to reduce flow disruptions in high-risk task episodes: resilience in robot-assisted surgery

In healthcare work settings, flow disruptions (FDs) pose a potential threat to patient safety. Resilience research suggests that adaptive behavioural strategies contribute to preventing cognitive overload through FDs at crucial moments. We aimed to explore the nature and efficacy of operating room (OR) team strategies to prevent FDs in robot-assisted surgery. Within a mixed-methods design, we first asked surgical professionals, which strategies they apply, and secondly, identified behavioural strategies through direct observations. Findings were analysed using content analysis. Additionally, FDs were assessed through live observations in the OR. The sample included four interviewed experts and 15 observed surgical cases. Sixty originally received strategies were synthesised into 17 final OR team strategies. Overall, 658 FDs were observed with external FDs being the most frequent. During high-risk episodes, FDs were significantly reduced (p < 0.0001). The identified strategies reveal how OR teams deliberatively and dynamically manage and mitigate FDs during critical tasks. Our findings contribute to a nuanced understanding of adaptive strategies to safeguard performance in robot surgery services. Practitioner Summary: Flow disruptions (FDs) in surgical work may become a severe safety threat during high-risk situations. With interviews and observations, we explored team strategies applied to prevent FDs in critical moments. We obtained a comprehensive list of behavioural strategies and found that FDs were significantly reduced during a specific high-risk surgical task. Our findings emphasise the role of providers' and teams' adaptive capabilities to manage workflow in high-technology care environments.

Systematic review of interruptions in the emergency department work environment

OBJECTIVE

The purpose of this systematic review is to describe the operationalization of interruptions measurement and to synthesize the evidence on the causes and consequences of interruptions in the emergency department (ED) work environment.

METHODS

This systematic review of studies explores the causes and consequences of interruptions in the ED. Of 2836 abstract/titles screened, 137 full-text articles were reviewed, and 44 articles met inclusion criteria of measuring ED interruptions.

RESULTS

All articles reported primary data collection, and most were cohort studies (n = 30, 68%). Conceptual or operational definitions of interruptions were included in 27 articles. Direct observation was the most common approach. In half of the studies, quantitative measures of interruptions in the ED were descriptive only, without measurements of interruptions' consequences. Twenty-two studies evaluated consequences, including workload, delays, satisfaction, and errors. Overall, relationships between ED interruptions and their causes and consequences are primarily derived from direct observation within large academic hospitals using heterogeneous definitions. Collective strengths of interruptions research in the ED include structured methods of naturalistic observation and definitions of interruptions derived from concept analysis. Limitations are conflicting and complex evaluations of consequences attributed to interruptions, including the predominance of descriptive reports characterizing interruptions without direct measurements of consequences.

CONCLUSIONS

The use of standardized definitions and measurements in interruptions research could contribute to measuring the impact and influence of interruptions on clinicians' productivity and efficiency as well as patients' outcomes, and thus provide a basis for intervention research.

Multi-institutional intervention to improve patient perception of physician empathy in emergency care

BACKGROUND

Physician empathy has been linked to increased patient satisfaction, improved patient outcomes and reduced provider burnout. Our objective was to test the effectiveness of an educational intervention to improve physician empathy and trust in the ED setting.

METHODS

Physician participants from six emergency medicine residencies in the US were studied from 2018 to 2019 using a pre-post, quasi-experimental non-equivalent control group design with randomisation at the site level. Intervention participants at three hospitals received an educational intervention, guided by acognitivemap (the 'empathy circle'). This intervention was further emphasised by the use of motivational texts delivered to participants throughout the course of the study. The primary outcome was change in E patient perception of resident empathy (Jefferson scale of patient perception of physician empathy (JSPPPE) and Trust in Physicians Scale (Tips)) before (T1) and 3-6 months later (T2).

RESULTS

Data were collected for 221 residents (postgraduate year 1-4.) In controls, the mean (SD) JSPPPE scores at T1 and T2 were 29 (3.8) and 29 (4.0), respectively (mean difference 0.8, 95% CI: -0.7 to 2.4, p=0.20, paired t-test). In the intervention group, the JSPPPE scores at T1 and T2 were 28 (4.4) and 30 (4.0), respectively (mean difference 1.4, 95% CI: 0.0 to 2.8, p=0.08). In controls, the TIPS at T1 was 65 (6.3) and T2 was 66 (5.8) (mean difference -0.1, 95% CI: -3.8 to 3.6, p=0.35). In the intervention group, the TIPS at T1 was 63 (6.9) and T2 was 66 (6.3) (mean difference 2.4, 95% CI: 0.2 to 4.5, p=0.007). Hierarchical regression revealed no effect of time×group interaction for JSPPPE (p=0.71) nor TIPS (p=0.16).

CONCLUSION

An educational intervention with the addition of text reminders designed to increase empathic behaviour was not associated with a change in patient-perceived empathy, but was associated with a modest improvement in trust in physicians.

Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection

OBJECTIVES

Interruptions occur frequently in the intensive care unit (ICU) and are associated with errors. To date, no causal connection has been established between interruptions and errors in healthcare. It is important to know whether interruptions directly cause errors before implementing interventions designed to reduce interruptions in ICUs. The aim of the study was to investigate whether ICU nurses who receive a higher number of workplace interruptions commit more clinical errors and procedural failures than those who receive a lower number of interruptions.

METHODS

We conducted a prospective controlled trial in a high-fidelity ICU simulator. A volunteer sample of ICU nurses from a single unit prepared and administered intravenous medications for a patient manikin. Nurses received either 3 (n = 35) or 12 (n = 35) scenario-relevant interruptions and were allocated to either condition in an alternating fashion. Primary outcomes were the number of clinical errors and procedural failures committed by each nurse.

RESULTS

The rate ratio of clinical errors committed by nurses who received 12 interruptions compared with nurses who received 3 interruptions was 2.0 (95% confidence interval = 1.41-2.83, P < 0.001). The rate ratio of procedural failures committed by nurses who received 12 interruptions compared with nurses who were interrupted 3 times was 1.2 (95% confidence interval = 1.05-1.37, P = 0.006).

CONCLUSIONS

More workplace interruptions during medication preparation and administration lead to more clinical errors and procedural failures. Reducing the frequency of interruptions may reduce the number of errors committed; however, this should be balanced against important information that interruptions communicate.

Addressing misconceptions of flow disruption studies in "Is non-stop always better? Examining assumptions behind the concept of flow disruptions in studies of robot-assisted surgery"

This letter to the editor provides a response to "Is non-stop always better? Examining assumptions behind the concept of flow disruptions in studies of robot-assisted surgery." The authors provide much needed clarification on misconceptions of flow disruption studies. The evolving methodology is not aimed at creating a "non-stop" flow, or optimizing efficiency, but understanding the clinical process from a systems perspective.

Identifying how GPs spend their time and the obstacles they face: a mixed-methods study

Background

Although problems that impair task completion — known as operational failures — are an important focus of concern in primary care, they have remained little studied.

Aim

To quantify the time GPs spend on different activities during clinical sessions; to identify the number of operational failures they encounter; and to characterise the nature of operational failures and their impact for GPs.

Design and setting

Mixed-method triangulation study with 61 GPs in 28 NHS general practices in England from December 2018 to December 2019.

Method

Time–motion methods, ethnographic observations, and interviews were used.

Results

Time–motion data on 7679 GP tasks during 238 hours of practice in 61 clinical sessions suggested that operational failures were responsible for around 5.0% (95% confidence interval [CI] = 4.5% to 5.4%) of all tasks undertaken by GPs and accounted for 3.9% (95% CI = 3.2% to 4.5%) of clinical time. However, qualitative data showed that time–motion methods, which depend on pre-programmed categories, substantially underestimated operational failures. Qualitative data also enabled further characterisation of operational failures, extending beyond those measured directly in the time–motion data (for example, interruptions, deficits in equipment/supplies, and technology) to include problems linked to GPs’ coordination role and weaknesses in work systems and processes. The impacts of operational failures were highly consequential for GPs’ experiences of work.

Conclusion

GPs experience frequent operational failures, disrupting patient care, impairing experiences of work, and imposing burden in an already pressurised system. This better understanding of the nature and impact of operational failures allows for identification of targets for improvement and indicates the need for coordinated action to support GPs.

Emergency Physicians' Workstation Design: An Observational Study of Interruptions and Perception of Collaboration During Shift-End Handoffs

BACKGROUND

Frequent external interruptions and lack of collaboration among team members are known to be common barriers in end-of-shift handoffs between physicians in the emergency department. In spite of being the primary location for this crucial and cognitively demanding task, workstations are not designed to limit barriers and support handoffs.

OBJECTIVE

The purpose of this study is to examine handoff characteristics, actual and perceived interruptions, and perceived collaboration among emergency physicians performing end-of-shift handoffs in physician workstations with varying levels of enclosures-(a) open-plan workstation, (b) enclosed workstation, and (c) semi-open workstation.

METHOD

Handoff and interruption characteristics were captured through in-person observations of 60 handoffs using an iPad-based tool. Additionally, physicians participating in the handoffs responded to a survey pertaining to their perception of interruptions and collaboration with clinicians during each phase. Other organizational and demographic data were obtained from the hospital database, surveys, and observations.

RESULTS

Physicians working in the open workstation experienced a significantly higher number of interruptions/hour (18.08 int/hr) as compared to the semi-open (13.62 int/hr) and enclosed workstations (11.41 int/hr). Most physicians perceived that they were interrupted in the semi-open and open workstations. In addition, majority of physicians in the enclosed pod perceived high collaboration with clinicians involved in and present in the workstation during handoff.

CONCLUSION

This correlational study showed positive outcomes experienced by physician working in the enclosed workstation as compared to the open and semi-open workstations.

Quantifying Emergency Physician Interruptions due to Electrocardiogram Review

BACKGROUND

Interruptions are recognized as potentially harmful to safety and efficiency, and are especially prevalent in the emergency department (ED) setting. Policies urging immediate review of all electrocardiograms (ECGs) may lead to numerous and frequent interruptions.

OBJECTIVE

We assessed the role of ECG review as a source of ED interruptions to characterize a potential target for interventions.

METHODS

We analyzed emergency physician time use during the course of a clinical shift using a time-and-motion design. A research assistant observed a convenience sample of shifts, observing and logging transitions between different tasks using an electronic device. Instances of ECG review were tallied, with start and ending times of ECG review recorded to the nearest second. An ECG review was considered an interruption if the immediate prior and subsequent tasks were the same.

RESULTS

Twenty shifts were observed for a total of 149 h. There were 211 ECG reviews, (mean rate 1.4 per hour), with more frequent review among physicians staffing a zone with higher-acuity patients (2.8 per hour), where clustering of multiple ECG reviews in succession was more common. Seventy-five percent of ECG reviews required < 30 s. Of all 211 ECG reviews, 102 (48%) were an interruption. The tasks most frequently interrupted were electronic medical record system use (68 of 102, 67%) and communicating with ED staff in person (18 of 102, 18%).

CONCLUSIONS

Review of ECGs was a substantial driver of interruptions for emergency physicians. Interventions to integrate ECG review more naturally into physician workflow may improve patient safety by reducing these interruptions.

Workflow disruptions and provider situation awareness in acute care: An observational study with emergency department physicians and nurses

BACKGROUND

The fast-paced and rapidly changing environment of an Emergency Department (ED) requires providers to have a high level of situation awareness (SA). However, acute clinical care also encompasses a multitude of interruption-laden work processes that might degrade SA. It is therefore important to understand how frequent interruptions affect ED provider cognition in general and SA in particular.

OBJECTIVE

We aimed to examine how sources and contents of provider workflow interruptions influence situation awareness of ED physicians and nurses.

METHODS

This prospective, multi-method study combined standardized observations, self-reports of ED providers, and ED administrative data of staffing and patient load. Expert observers identified ED providers' workflow interruptions during 90min observation sessions. Afterwards, each provider reported perceived disruptiveness and situation awareness. Controlling for patient load, patient acuity and staffing, we conducted regression analyses to explore prospective associations between interruptions and provider outcomes.

RESULTS

During 74 observation sessions of overall 110h and 40min, we observed 1205 workflow interruptions (mean rate: 10.9 interruptions/hour). Provider situation awareness was fairly high (M = 7.10; scale 0-10) with no difference between ED physicians and nurses. After controlling for ED workload data, we observed that high rates of interruptions were associated with lower levels of situation awareness (β = -0.27). Further analyses revealed that particularly interruptions by telephone/beeper, technical malfunctions as well as interruptive communication related to completed cases were correlated to low SA.

DISCUSSION

This study in a naturalistic ED setting shows that ED physicians and nurses continuously cope with disruptions and interruptions. Our findings reveal that highly interruptive workflow environments impede providers' situation awareness. Moreover, it sheds light on specific sources and contents of interruptions that influence providers' SA in acute care.

CONCLUSION

Frequent workflow interruptions can degrade ED providers' situation awareness. A deeper understanding of how avoidable and unavoidable interruptions affect provider cognitions with particular focus on social and technology-related disruptions is required. Further emphasis should be placed on the effective application of work re-design in this context to foster safe and efficient patient care.

Physicians' and nurses' work time allocation and workflow interruptions in emergency departments: a comparative time-motion study across two countries

BACKGROUND

Globally, emergency department (ED) work is fast-paced and subject to interruptions, placing high coordination and communication demands on staff. Our study aimed to compare ED staffs' work time allocation and interruption rates across professional roles and two national settings.

METHODS

We conducted a time-motion study with standardised expert observations of ED physicians and nurses in Germany and the USA. Observers coded ED staffs' activities and workflow interruptions. General and generalised linear models were used to examine differences in activities and interruption rates between countries and ED professions.

RESULTS

28 observations were conducted in the USA and 30 in Germany. Overall, the largest portion of time spent by ED staff in both settings was in documentation (22.0%). Physicians spent more time in verbal interaction with patients (9.9% vs 5.2% in nurses; p=0.006), in documentation (29.4% vs 15.6%; p<0.001) and other professional activities (13.0% vs 4.8%; p=0.002). Nurses allocated significantly more time to therapeutic (22.3% vs 6.0% in physicians; p<0.001) and organisational activities (20.4% vs 9.5%; p<0.001). Overall mean interruption rate per hour was 10.16 (US ED: 8.15, German ED: 12.04; p<0.001). American physicians and German nurses were most often disrupted by colleagues of the same profession (country: B=-.27, p=0.027; profession: B=0.35, p=0.006). German ED staff were interrupted more often by patients (B=-.78, p=0.001) and other sources (B=-.76, p<0.001) than American ED staff.

DISCUSSION

Our findings corroborate that professional roles largely determine time allocation to specific activities. However, interruption rates indicate differences between countries, suggesting the need for context-specific solutions to work stressors.

Diagnosing rare diseases: A sociotechnical approach to the design of complex work systems

How do complex healthcare systems that are organised into distinct speciality areas achieve effective patient care transitions when patients present with a rare constellation of symptoms that affect multiple body systems? How do these patients challenge existing ways of organising tasks, clinical activities, and interdependent responsibilities? The current study applies a sociotechnical systems perspective to understand how these complex work design and care-related challenges were resolved by the Western Australian Undiagnosed Diseases Program. We conducted a two-year longitudinal, qualitative study of this program, conceived to improve the diagnosis and management of patients with rare, multi-system disorders by piloting a re-design of the local system of diagnostic work. Specifically, we (1) compared the configuration and effectiveness of the old system and the re-designed system; and (2) analysed the process of system re-design (i.e., the design, implementation, and operation of the program) in order to understand the factors that contributed to - or inhibited - its success. We discuss the theoretical and practical implications of our findings for effectively re-designing complex, trans-organisational work systems.

Improving Team-Based Decision Making Using Data Analytics and Informatics: Protocol for a Collaborative Decision Support Design

Background

According to the September 2015 Institute of Medicine report, Improving Diagnosis in Health Care, each of us is likely to experience one diagnostic error in our lifetime, often with devastating consequences. Traditionally, diagnostic decision making has been the sole responsibility of an individual clinician. However, diagnosis involves an interaction among interprofessional team members with different training, skills, cultures, knowledge, and backgrounds. Moreover, diagnostic error is prevalent in the interruption-prone environment, such as the emergency department, where the loss of information may hinder a correct diagnosis.

Objective

The overall purpose of this protocol is to improve team-based diagnostic decision making by focusing on data analytics and informatics tools that improve collective information management.

Methods

To achieve this goal, we will identify the factors contributing to failures in team-based diagnostic decision making (aim 1), understand the barriers of using current health information technology tools for team collaboration (aim 2), and develop and evaluate a collaborative decision-making prototype that can improve team-based diagnostic decision making (aim 3).

Results

Between 2019 to 2020, we are collecting data for this study. The results are anticipated to be published between 2020 and 2021.

Conclusions

The results from this study can shed light on improving diagnostic decision making by incorporating diagnostics rationale from team members. We believe a positive direction to move forward in solving diagnostic errors is by incorporating all team members, and using informatics.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16047

Interruptions in Health Care: Assessing Their Connection With Error and Patient Harm

OBJECTIVE

We address the problem of how researchers investigate the actual or potential causal connection between interruptions and medical errors, and whether interventions might reduce the potential for harm.

BACKGROUND

It is widely assumed that interruptions lead to errors and patient harm. However, many reviewers and authors have commented that there is not strong evidence for a causal connection.

METHOD

We introduce a framework of criteria for assessing how strongly evidence implies causality: the so-called Bradford Hill criteria. We then examine four key "metanarratives" of research into interruptions in health care-applied cognitive psychology, epidemiology, quality improvement, and cognitive systems engineering-and assess how each tradition has addressed the causal connection between interruptions and error.

RESULTS

Outcomes of applying the Bradford Hill criteria are that the applied cognitive psychology and epidemiology metanarratives address the causal connection relatively directly, whereas the quality improvement metanarrative merely assumes causality, and the cognitive systems engineering metanarrative either implicitly or explicitly questions the feasibility of finding a direct causal connection with harm.

CONCLUSION

The Bradford Hill criteria are useful for evaluating the existing literature on the relationship between interruptions in health care, clinical errors, and the potential for patient harm. In the future, more attention is needed to the issue of why interruptions usually do not lead to harm, and the implications for how we approach patient safety.

Interruptions and Delivery of Care in the Intensive Care Unit

OBJECTIVE

This study samples interruption frequency in intensive care unit (ICU) settings to assess the relationship between interruptions and common patient hazards.

BACKGROUND

Task interruptions are accident contributors in numerous industries. Recently, studies on health care interruptions and their impact on patient hazards have received attention.

METHOD

Seven ICUs in four hospitals participated in a 24-month study. Experienced ICU nurses directly observed nursing tasks, interruptions, and patient hazards (delays in care, breaks in device task protocols, and patient safety hazards).

RESULTS

During 1,148 hours of observation, 175 nurses performed 74,733 nursing tasks. Interruptions occurred at a rate of 4.95 per hour, and 8.4% of tasks were interrupted. Interruptions originated mostly from humans (65.9%), alarms (24.1%), and others (10%). A total of 774 patient hazards were observed, with a hazard occurring on average every 89 minutes. Relative to noninterrupted tasks, device alarm interrupted nonstructured tasks were associated with increased rates of delays in care and safety hazards (rate ratio [RR] = 3.19). In contrast, rate of delays in care and safety hazards did not increase during human interrupted tasks (RR = 1.13). Rates of protocol nonadherence varied by device type and were highest during artificial airway, medication administration, chest tube, and supplemental oxygen management.

CONCLUSION

Interruptions in the ICU are frequent and contribute to patient hazards, especially when caused by device alarms during nonstructured tasks. Nonadherence to protocols is common and contributed to patient hazards.

APPLICATION

The findings suggest a need for improvement in task and device design to reduce patient hazards.

Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study

OBJECTIVES

The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

DESIGN

Prospective observational study using the Work Observation Method By Activity Timing tool.

SETTING

An OR department at a county hospital in Sweden.

PARTICIPANTS

OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

RESULTS

The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

CONCLUSIONS

The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

TRIAL REGISTRATION NUMBER

2016/264.

Perceived vs. actual distractions in the emergency department

INTRODUCTION

The emergency department (ED) has been shown to be an interrupt-driven workplace fraught with potential for distractions and interruptions that increase the potential for medical error. Accuracy of provider perception of these distractions and interruptions has yet to be investigated.

METHODS

An observational two-phase study was conducted over a 9-week period in the highest acuity zone of the ED at an urban, academic medical center with about 90,000 visits/year. Phase I, conducted over the initial 5-weeek period, consisted of observers recording the type and frequency of all overhead pages in the ED. In phase II, conducted over the final 4-week period, direct observation of faculty and residents was done to record all individual interruptions for different levels of training. Actual data was compared to provider perceptions, as determined by survey responses.

RESULTS

2438 overhead pages were recorded and occurred, on average, 23.2 times per shift. The perceived rate of overhead pages was 43.2 per shift. 333 individual interruptions occurred, on average, 4.26 times per shift. The perceived rate was 53.5 per shift. Attending providers perceived a significantly higher number of individual interruptions compared to all resident providers.

CONCLUSION

The perceived amount and rate of distractions and interruptions are significantly higher than the actual amount and rate of distractions and interruptions. Attending physicians both perceive and experience more distractions and interruptions. Further work should be done to evaluate the power of provider perception, and the potential contribution of inaccurate perception to medical error and provider burnout.

Effects of work conditions on provider mental well-being and quality of care: a mixed-methods intervention study in the emergency department

BACKGROUND

Emergency departments (EDs) are highly dynamic and stressful care environments that affect provider and patient outcomes. Yet, effective interventions are missing. This study evaluated prospective effects of a multi-professional organizational-level intervention on changes in ED providers' work conditions and well-being (primary outcomes) and patient-perceived quality of ED care (secondary outcome).

METHODS

A before and after study including an interrupted time-series (ITS) design over 1 year was established in the multidisciplinary ED of a tertiary referral hospital in Southern Germany. Our mixed-methods approach included standardized provider surveys, expert work observations, patient surveys, and register data. Stakeholder interviews were conducted for qualitative process evaluation. ITS data was available for 20 days pre- and post-intervention (Dec15/Jan16; Dec16/Jan17). The intervention comprised ten multi-professional meetings in which ED physicians and nurses developed solutions to work stressors in a systematic moderated process. Most solutions were consecutively implemented. Changes in study outcomes were assessed with paired t-tests and segmented regression analyses controlling for daily ED workload.

RESULTS

One hundred forty-nine surveys were returned at baseline and follow-up (response at baseline: 76 out of 170; follow-up: 73 out of 157). Forty-one ED providers participated in both waves. One hundred sixty expert work observations comprising 240 observation hours were conducted with 156 subsequent work stress reports. One thousand four hundred eighteen ED patients were surveyed. Considering primary outcomes, respondents reported more job control and less overtime hours at follow-up. Social support, job satisfaction, and depersonalization deteriorated while respondents' turnover intentions and inter-professional interruptions increased. Considering the secondary outcome, patient reports indicated improvements in ED organization and waiting times. Interviews revealed facilitators (e.g., comprehensive approach, employee participation) and barriers (e.g., understaffing, organizational constraints) for intervention implementation.

CONCLUSIONS

To the best of our knowledge, this is the first study to report prospective effects of an ED work system intervention on provider well-being and patient-perceived quality of ED care. We found inconsistent results with partial improvements in work conditions and patient perceptions of care. However, aspects of provider mental well-being deteriorated. Given the lack of organizational-level intervention research in EDs, our findings provide valuable insights into the feasibility and effects of participatory interventions in this highly dynamic hospital setting.

Effects of Interruptions on Triage Process in Emergency Department: A Prospective, Observational Study

For 130 million people seeking emergency treatment in the United States, incomplete or inaccurate triage examination can result in delays, which could compromise patient outcomes. The purpose of this study was to identify triage interruptions and determine how interruptions affect the triage process. A significant difference was seen in triage duration between interrupted and uninterrupted interviews. Understanding the impact of interruptions on patient outcomes will allow nurses and other health care providers to develop interventions to mitigate the impact.

Provider interruptions and patient perceptions of care: an observational study in the emergency department

BACKGROUND

Interruptions are endemic in healthcare work environments. Yet, they can have positive effects in some instances and negative in others, with their net effect on quality of care still poorly understood. We aimed to distinguish beneficial and detrimental forms of interruptions of emergency department (ED) providers using patients' perceptions of ED care as a quality measure.

METHODS

An observational design was established. The study setting was an interdisciplinary ED of an academic tertiary referral hospital. Frequencies of interruption sources and contents were identified in systematic expert observations of ED physicians and nurses. Concurrently, patients rated overall quality of care, ED organisation, patient information and waiting times using a standardised survey. Associations were assessed with hierarchical linear models controlling for daily ED workload. Regression results were adjusted for multiple testing. Additionally, analyses were computed for ED physicians and nurses, separately.

RESULTS

On 40 days, 160 expert observation sessions were conducted. 1418 patients were surveyed. Frequent interruptions initiated by patients were associated with higher overall quality of care and ED organisation. Interruptions relating to coordination activities were associated with improved ratings of ED waiting times. However, interruptions containing information on previous cases were associated with inferior ratings of ED organisation. Specifically for nurses, overall interruptions were associated with superior patient reports of waiting time.

CONCLUSIONS

Provider interruptions were differentially associated with patient perceptions of care. Whereas coordination-related and patient-initiated interruptions were beneficial to patient-perceived efficiency of ED operations, interruptions due to case-irrelevant communication were related to inferior patient ratings of ED organisation. The design of resilient healthcare systems requires a thorough consideration of beneficial and harmful effects of interruptions on providers' workflows and patient safety.

Understanding Emergency Medicine Physicians Multitasking Behaviors Around Interruptions

BACKGROUND

Interruptions can adversely impact human performance, particularly in fast-paced and high-risk environments such as the emergency department (ED). Understanding physician behaviors before, during, and after interruptions is important to the design and promotion of safe and effective workflow solutions. However, traditional human factors-based interruption models do not accurately reflect the complexities of real-world environments like the ED and may not capture multiple interruptions and multitasking.

METHODS

We present a more comprehensive framework for understanding interruptions that is composed of three phases, each with multiple levels: interruption start transition, interruption engagement, and interruption end transition. This three-phase framework is not constrained to discrete task transitions, providing a robust method to categorize multitasking behaviors around interruptions. We apply this framework in categorizing 457 interruption episodes.

RESULTS

A total of 457 interruption episodes were captured during 36 hours of observation. The interrupted task was immediately suspended 348 (76.1%) times. Participants engaged in new self-initiated tasks during the interrupting task 164 (35.9%) times and did not directly resume the interrupted task in 284 (62.1%) interruption episodes.

CONCLUSION

Using this framework provides a more detailed description of physician behaviors in complex environments. Understanding the different types of interruption and resumption patterns, which may have a different impact on performance, can support the design of interruption mitigation strategies.

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study

BACKGROUND

Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals' task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied.

OBJECTIVE

To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors.

METHODS

36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians' working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep.

RESULTS

Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.

CONCLUSION

Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments.

Improving Care Transitions Across Healthcare Settings Through a Human Factors Approach

After more than two decades of research focused on care transition improvement and intervention development, unfavorable outcome measures associated with care transitions across healthcare settings persist. Readmissions rates remain an important outcome to target for intervention, adverse events associated with care transitions continue to be an issue, and patients are often dissatisfied with the quality of their care. Currently, interventions to improve care transitions are disease specific, require substantial financial investments in training allied healthcare professionals, or focus primarily on hospital-based discharge planning with mixed results. This complex situation requires a method of evaluation that can provide a comprehensive, in-depth, and context-driven investigation of potential risks to safe care transitions across healthcare settings, which can lead to the creation of effective, usable, and sustainable interventions. A systems' approach known as Human Factors and Ergonomics (HFE) evaluates the factors in a system that affect human performance. This article describes how HFE can complement and further strengthen efforts to improve care transitions.

Modelling interactions between procedures and resilience skills

Although work in complex socio-technical systems needs support from several "resources for action", the interactions between these are not usually managed systematically. This study introduces a six-step framework for analyzing the interactions between two key resources for action, namely the use of standardized operating procedures and resilience skills (RSs). The main steps for applying the framework involve: (i) a content analysis of the procedure, which allows for the identification of underspecified rules and situations that could be emphasized in scenario-based training focused on developing RSs; and (ii) the identification of factors that set the stage for the emergence of RSs, which could be accounted for by procedures and the broader work system design. An application of the framework is presented in the preparation and administration of intravenous medications in an emergency department. Data collection involved 98 h of observations, 14 interviews, and document analysis. Based on this field study, a model of the interactions between procedures and RSs is proposed as well as the lessons learned from applying the framework are discussed.

Applying social network analysis to the examination of interruptions in healthcare

Examinations of interruptions in healthcare often focus on a single clinical discipline, and solutions are targeted accordingly. This approach does not take into account the inter-disciplinary dependencies and other sociotechnical aspects that make up the healthcare work system, and suggested solutions may not meet the needs of all stakeholders. In this article a sociotechnical systems perspective is used to uncover the interdependencies between 16 unique work roles that result in interruptions in an intensive care unit (ICU). By applying social network analysis techniques to data collected using the Dual Perspectives Method, we identified targeted systems-based interventions that may reduce unnecessary interruptions while avoiding unintended consequences that impose additional burden on ICU staff. The rich insights gained into the interruptive communication patterns in the ICU work system stand in contrast to findings that would have otherwise been obtained by focusing only on a single clinical discipline or a single perspective.

Quantifying the Qualitative with Epistemic Network Analysis: A Human Factors Case Study of Task-Allocation Communication in a Primary Care Team

Health care is fundamentally about people, and therefore, engineering approaches for studying healthcare systems must consider the perspective, concepts and methods offered by the human factors and ergonomics (HFE) discipline. HFE analysis is often qualitative to provide in-depth description of work systems and processes. To deepen our understanding of care processes, we propose the next level of analysis, i.e. quantification of qualitative data. Here, we describe epistemic network analysis (ENA) as a novel method to quantify qualitative data and present a case study applying ENA to assess communication in a primary care team. One high-performing primary care team consisting of a physician, nurse, medical assistant and unit clerk was observed for 15 hours. We analyzed task-allocation communications and identified the sender, receiver, synchronicity and acceptance. We used logistic regression and ENA to evaluate sender, receiver and synchronicity impact on task acceptance. The physician and unit clerk were most successful allocating tasks. Future work should consider the role of synchronous, interruptive communication as potentially useful in time-critical tasks and further investigate the role of the unit clerk. HFE researchers should consider ENA as a tool to expand and deepen their understanding of care processes by quantifying qualitative data.

Workflow interruptions and stress atwork: a mixed-methods study among physicians and nurses of a multidisciplinary emergency department

OBJECTIVES

Dealing with multiple workflow interruptions is a major challenge in emergency department (ED) work. This study aimed to establish a taxonomy of workflow interruptions that takes into account the content and purpose of interruptive communication. It further aimed to identify associations of workflow interruptions with ED professionals' work stress.

DESIGN

Combined data from expert observation sessions and concomitant self-evaluations of ED providers.

SETTING

ED of an academic community hospital in Germany.

PARTICIPANTS

Multidisciplinary sample of ED physicians and nurses. 77 matched observation sessions of interruptions and self-evaluations of work stress were obtained on 20 randomly selected days.

OUTCOME MEASURES

ED professionals' stress evaluations were based on standardised measures. ED workload data on patient load, patient acuity and staffing were included as control variables in regression analyses.

RESULTS

Overall mean rate was 7.51 interruptions/hour. Interruptions were most frequently caused by ED colleagues of another profession (27.1%; mean interruptions/hour rate: 2.04), by ED colleagues of the same profession (24.1%; 1.81) and by telephone/beeper (21%; 1.57). Concerning the contents of interruption events, interruptions most frequently occurred referring to a parallel case under care (30.3%, 2.07), concerning the current case (19.1%; 1.28), or related to coordination activities (18.2%, 1.24). Regression analyses revealed that interruptive communication related to parallel cases significantly increased ED providers' stress levels (β=0.24, P=0.03). This association remained significant after controlling for ED workload.

DISCUSSION

Interruptions that refer to parallel cases under care were associated with increased stress among ED physicians and nurses. Our approach to distinguish between sources and contents of interruptions contributes to an improved understanding of potential benefits and risks of workflow interruptions in ED work environments. Despite some limitations, our findings add to future research on the implications of interruptions for effective and safe patient care and work in complex and dynamic care environments.

Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department

BACKGROUND

It is unclear how workflow interruptions impact emergency physicians at the point of care.

OBJECTIVES

Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians.

METHODS

This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms.

RESULTS

A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ²(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ² [2, n = 2355] = 78.43, p < 0.001).

CONCLUSIONS

Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.

Modeling Task Scheduling in Complex Healthcare Environments: Identifying Relevant Factors

Multiple task coordination involves scheduling tasks, completing tasks, and integrating tasks into a workflow. Task scheduling can influence outcomes of safety, satisfaction, and efficiency when completing tasks. This is especially important in complex life-critical environments such as healthcare, which incurs many situations where there are multiple tasks and limited resources for addressing all tasks. One approach for understanding tasks coordination is the Strategic Task Overload Management (STOM) model, which is a model for task scheduling behavior. In this theoretical paper, we discuss how this model can be extended to a complex healthcare environment. There are additional considerations (e.g., time) which must be considered when applying this model to healthcare. Ultimately, understanding how emergency physicians make multiple task scheduling decisions will advance theories and models, such as STOM, which can then in turn be implemented to improve scheduling behaviors in complex healthcare environments.

Missing mediated interruptions in manual assembly: Critical aspects of breakpoint selection

The factory of the future aims to make manufacturing more effective and easily customisable, using advanced sensors and communications to support information management. In this paper, we examine how breakpoint selection during interruption management can fail, even when using recommendations for interruption management from existing research. We present an experiment based on prior work where mediated interruptions (i.e. smart interruptions that should interrupt at opportune moments) were missed by participants when sent at one of two pre-defined breakpoints. These breakpoints were selected based on existing research to minimise the cost of interruption, which can involve longer times to complete tasks as well as making errors on tasks. Missing mediated interruptions in this way was unexpected, and the prior study was not configured to measure this effect, which has led to the experiment detailed here. We strive to explore whether there is a risk of missing notifications when mediated interruptions are used, and how this is affected by breakpoint selection. This was investigated through an experiment that uses tasks and environments that simulate a manufacturing assembly facility. The results indicate that the effect exists, i.e. that participants miss significantly more notifications when interrupted at fine breakpoints than when interrupted at coarse breakpoints. An embodied cognition perspective was used for analysis of the tasks to understand the cause of the effect. This analysis shows that an overlap between "action" and "anticipation of action" can account for why participants miss notifications at fine breakpoints. Based on these findings, recommendations were developed for designing interruption systems that minimise the costs (errors and time) imposed by interruptions during assembly tasks in manufacturing.

Two sides to every story: The Dual Perspectives Method for examining interruptions in healthcare

Interruptions are widely considered a problem in healthcare. Results from observation and experimental studies have guided extensive mitigation efforts, but the effectiveness of interventions remains mixed. We have built on current theories and methods for studying interruptions to develop a novel observational approach - the Dual Perspectives Method - for examining interruptions from the perspectives of the different work functions in an Intensive Care Unit (ICU). We detail the method and provide representative examples of the insights it offers, such as why interruptions happen, the role they play, and the consequences of preserving them or eliminating them. We anticipate that the Dual Perspectives Method will help us to arrive at a better basis on which to draw conclusions about interruptions, and will lead to the development of appropriate and sustainable interventions to ensure the effective and safe functioning of the work system under examination.

Emergency doctors' strategies to manage competing workload demands in an interruptive environment: An observational workflow time study

An observational workflow time study was conducted involving doctors in the emergency department (ED) of a large Australian hospital. During 121.7 h across 58 sessions, we observed interruptive events, conceptualised as prompts, and doctors' strategies to handle those prompts (task-switching, multitasking, acknowledgement, deferral and deflection) to assess the role of multiple work system factors influencing doctors' work in the ED. Prompt rates varied vastly between work scenarios, being highest during non-verbal solo tasks. The propensity to use certain strategies also differed with task type, prompt type and location within the department, although task-switching was by far the most frequent. Communicative prompts were important in patient treatment and workload management. Clinicians appear to adjust their communication strategies in response to contextual factors in order to deliver patient care. Risk due to the interruptive nature of ED communication is potentially outweighed by the positive effects of timely information transfer and advice provision.

Macroergonomic factors in the patient work system: examining the context of patients with chronic illness

Human factors/ergonomics recognises work as embedded in and shaped by levels of social, physical and organisational context. This study investigates the contextual or macroergonomic factors present in the health-related work performed by patients. We performed a secondary content analysis of findings from three studies of the work of chronically ill patients and their informal caregivers. Our resulting consolidated macroergonomic patient work system model identified 17 factors across physical, social and organisational domains and household and community levels. These factors are illustrated with examples from the three studies and discussed as having positive, negative or varying effects on health and health behaviour. We present three brief case studies to illustrate how macroergonomic factors combine across domains and levels to shape performance in expected and unexpected ways. Findings demonstrate not only the importance of context for patients' health-related activities but also specific factors to consider in future research, design and policy efforts. Practitioner Summary: Health-related activities of patients are embedded in and shaped by levels of social, physical and organisational context. This paper combined findings from three studies to specify 17 contextual or macroergonomic factors in home- and community-based work systems of chronically ill patients. These factors have research, design and policy implications.

Traditions of research into interruptions in healthcare: A conceptual review

BACKGROUND

Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations.

OBJECTIVE

To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research.

METHODS

A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community's motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community.

RESULTS

A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities.

CONCLUSIONS

Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions.