1. 1 Operational Failures and Interruptions in Hospital Nursing Anita L. Tucker, Assistant Professor, Wharton and Steven J. Spear, IHI Cincinnati Innovations in Healthcare Delivery September 22, 2006

2. 2 Motivations for studying nurses’ work environment Nurses’ work has a direct impact on patient outcomes More nursing care = better outcomes (Aiken et al, 2002; Kovner et al., 2002; Needleman et al., 2002) Typical Policy suggestion: Increase Nursing Staff, but is challenging Nursing shortage (Buerhaus et al., 2000) Expensive Increasing documentation takes time away from patient care (Beaudoin and Edgar, 2003) Need to investigate and improve nurses’ work environment (JCAHO 2002, Page 2004) Increase nurses’ job satisfaction and retention Reduce work requirements that take time away from patient care

3. 3 Alternate Recommendation Improving work systems by reducing Operational failures (Tucker 2004; Beaudoin & Edgar 2003) Disruptions in employees’ abilities to effectively complete tasks due to problems or errors in supply of information or materials Reducing operational failures can lead to Fewer interruptions (may reduce medical errors) More time to care for patients

4. 4 Examples of Operational Failures on Nursing Units TypeProblemsErrors Information- Unsure what supplies surgeon wants - Change of shift doesn’t mention patient was nauseous - Patient not being observed by any nurse Materials - Missing linen - -Missing container - Sputum sample lost on way to lab Equipment- Can’t find thermometer- Nurse mistakenly left sleeping infant on ICU bed after transfer to regular floor Medications- Missing medications- Nurse forgot to give patient his medications all shift

5. 5 Research Questions To what extent do operational failures interfere with effective nursing work? How do operational failures shape the nursing work environment?

6. 6 Methods: 3 Sources of Data Direct Observation 11 nurses at 6 hospitals, each for a complete shift Mean observation time: 9 hours 51 minutes Recorded minute-by-minute information about their work activities Interviews Structured interviews with 6 of the observed nurses Nurse’s perceptions of how operational failures affect productivity and patient care Survey Data (520 nurses in 48 units at 21 hospitals) # of times experienced operational failures during last shift I started to prepare a patient’s medication, but it was missing or incorrect Also surveyed Managers from those units: # of operational failures (i.e. medication, orders, equipment, supplies) nurses encountered per shift

7. 7 Findings: Frequency of Operational Failures

8. 8 Findings: Nature of Nursing Work Workload pressure Worked 45 minutes of unscheduled overtime at end of shift to “catch up” Staccato Pace of Work Average task time: 3.1 minutes Nurses switched among patients every 11 minutes Time-specific procedures Administering medications within certain time periods Monitoring vital signs during and after blood transfusions Preparing patients for procedures (i.e. surgery) Wide breadth of responsibilities 84 different types of activities Cognitive components, such as administering medications that were contingent upon the patient’s laboratory test results or vital signs Frequent Interruptions Interrupted mid-task 8 times per 8-hr shift

9. Lois* experienced frequent interruptions Even her interruptions were interrupted! 8 interruptions in total to “Target Task” 3 sets of interrupted tasks: Preparing TPN, IV, Discharge patient * All names disguised to protect confidentiality

10. 10 Findings: Three Tactics for Managing Workload Planning Work 1.Partition Spread care for each patient over shift (rather than one block) Often due to medical necessity (assess vital signs every 2 hrs) 2.Interweave Switch back and forth between different patients’ care Managing disruptions to the plan 3.Reprioritization Adapt work plans by adding, subtracting, and reordering tasks as patients’ conditions changed Newly admitted patients often caused reprioritization as nurses had to fit the new patient into their work loads

11. 11 Nurse Kendra Brown*’s Day Partition Interweave Reprioritize While working on discharging Mr. Q, Mr. B. complained of chest pain

12. 12 Implications of the three tactics Tactics may be associated with error because they introduce Delays Delays in completing a task can cause a person to forget to return to the task (Reason 1990) Interruptions Interruptions can cause a person to pick up a task at the wrong point, repeating or omitting steps, or doing the right task, but on the wrong object/person (Rudolph and Repenning, 2002; Flynn et al., 1999) Distractions Medical errors have occurred when healthcare professionals receive wrong or incomplete information or materials (i.e. Chassin and Becher, 2002)

13. 13 Quote about recalling interrupted tasks “I am in [a patient room] trying to do a medication, priming the IV tubing. The phone rings, the clerk comes and gets me. I stop what I am doing, dial the flow clamp off, hang it over the IV pole, walk out and deal with the phone call. Then someone else comes and asks me, ‘Can you come and help with whatever.’ And I totally forget I have this IV that I really haven't hung and haven't given to the patient yet. Until I walk back in the room again-usually pretty quickly-and see the IV hanging there and say ‘shoot I really need to get that going.’” - Norma Garvin, Shock/Trauma H9

14. 14 Partitioning and human error Requires nurses to recall what has already been done and what remains to be done “Mental bookkeeping” (Cook and Woods 1994) Interdependencies among tasks (i.e. patient awaiting surgery needs lab tests done, but no food or water) If stock of undone tasks increases faster than they are completed, it causes stress, decreasing cognitive processing (Rudolph and Repenning 2003) and conflicting priorities (i.e. productivity versus quality) Operational failures can increase stock of undone tasks (i.e. administering medication)

15. 15 Interweaving Care and human error Switching back and forth requires “recovery time” to bring details of patient’s case to the forefront (Speier et al, 1999), especially with complex work. Can lead to accidentally mixing up patient details Operational failures can lead to more switches

16. 16 Reprioritization and human error Additional cognitive load because Attention process: determine whether interruption should be addressed Strategic process: determine which goals get priority (Cook and Woods 1994) Increases stress when have to abandon task that was originally planned Operational failures can cause reprioritization 25 minutes delay in getting Mr. Bartlett his medication because Dr. did not realize Ms. Rollins amputation was that day and he needed to come and sign consent form in the hour before surgery

17. 17 Findings: operational failures’ impact Type Operational Failure caused Patient care caused Total 1. Partition18 (35%)34 (65%)52 2. Interweaving15 (2%)714 (98%)729 3 reprioritization8 (9.4%)77 (90.6%)85 4. Interruptions4 (4.5%)85 (95.5%)89 Total45 (4.7%)910 (95%)955

18. 18 DISCUSSION Conditions inherent to meeting patient needs make 95% of the interweaving and reprioritization unavoidable Design nursing processes to minimize negative impact of interruption Mistake-proofing and human factors engineering: Design physical space to make it more difficult to commit errors, even if interrupted (Grout 2003) Visual Signals to Reduce Interruptions (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 (IOM 2004) Filter messages through a secretary or by provide nurses with enough information to triage their messages (IOM 2004)

19. 19 DISCUSSION 5% stem from operational failures and are avoidable Improve work systems by removing known problems Use failure occurrence to trigger removal of underlying causes, rather than the common approach of relying on people to work around failures (Spear, and Schmidhofer 2005; Tucker, Edmondson, and Spear 2002)

20. 20 Conclusion: Two Avenues for Improvement Operational Failures What: Problems or errors in supply of materials, information, and equipment to health care professionals. Avoidable Response: Work around failure to provide patient care Strategy: Improve work systems to reduce future occurrences Nature of health care What: New information about a patient’s health status becomes evident Unavoidable Response: Need to update the patient’s plan of care to reflect new knowledge Strategy: Design health care work to be robust to interruption