Designing for distractions: A human factors approach to decreasing interruptions at a centralised medication station

BMJ Quality and Safety

Volumn 21, Issue 11, 2012, Pages 939-947

  Colligan, Lacey ^a   Guerlain, Stephanie ^b   Steck, Susan E ^a   Hoke, Tracey R ^a  

^a UNIVERSITY OF VIRGINIA HEALTH SYSTEM   (United States)

^b University of Virginia   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; AWARENESS; HEALTH CARE DELIVERY; HEALTH CARE PERSONNEL; HOSPITAL ORGANIZATION; HUMAN; MEDICATION ERROR; NURSE; NURSING CARE; PATIENT CARE; SEMI STRUCTURED INTERVIEW; ATTENTION; HEALTH PERSONNEL ATTITUDE; HOSPITAL INFORMATION SYSTEM; HOSPITAL MANAGEMENT; PUBLIC RELATIONS; STANDARDS; UTILIZATION; WORKFLOW;

ATTENTION; ATTITUDE OF HEALTH PERSONNEL; CENTRALIZED HOSPITAL SERVICES; HUMANS; INTERPROFESSIONAL RELATIONS; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; POINT-OF-CARE SYSTEMS; WORKFLOW;

EID: 84871882932     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2011-000289     Document Type: Article

References (32)

1. Institute of Medicine. Crossing the Quality Chasm: A New Healthcare System for the 21st Century. Washington DC: National Academy Press, 2001:4.
2. National Academy of Medicine and Institute of Medicine. Building a Better Delivery System: A New Engineering/Healthcare Partnership. Washington DC: The National Academies Press, 2005:31.
3. Wilson J. Methods in the understanding of human factors. In: Wilson J, Corlett N, eds. Evaluation of Human Work. 3rd edn. Boca Raton FL: Taylor & Francis, 2005:4.
4. Coiera E, Tombs VS. Communication behaviours in a hospital setting; an observational study. BMJ 1998;316:673-7.
5. Flynn EA, Barker KN, Gibson JT, et al. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Health Syst Pharm 1999;56:1319-25. (Pubitemid 29316094)
6. Chisholm CD, Dornfeld AM, Nelson DR, et al. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001;38:146-51. (Pubitemid 32702280)
7. Ebright PR, Patterson ES, Chalko BA, et al. Understanding the complexity of registered nurse work in acute care settings. J Nurs Adm 2003;33:630-8. (Pubitemid 37543349)
8. Brixey JJ, Robinson DJ, Tang Z, et al. Interruptions in workflow for RNs in a level one Trauma Center. AMIA Annu Symp Proc 2005:86-90.
9. Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform 2009;78:293-307.
10. Rivera-Rodriguez AJ, Karsh B. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care 2010;19:304-12.
11. Reason J. Human Error. Cambridge England: Cambridge University Press, 1990:71.
12. Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an Increased risk and severity of medication administration errors. Arch Intern Med 2010;170:683-90.
13. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-20. (Pubitemid 32367829)
14. Page A. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington DC: The National Academies Press, 2004:250.
15. Dismukes K, Young G, Sumwalt R. Cockpit Interruptions and Distractions: effective management requires a careful balancing act. ASRS Directline 1998;10:4-8.
16. Relihan E, O'Brien V, O'Hara S, et al. The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Qual Saf Health Care. Published Online First: 28 May 2010. doi:10.1136/qshc.2009.036871
17. Anthony K, Wiencek C, Bauer C, et al. No interruptions Please: impact of a No Interruption Zone on medication safety in intensive care units. Crit Care Nurse 2010;30:21-9.
18. Agency for Healthcare Research and Quality. Appendix E: case studies in high reliability applications: medication dispensing machine redesign and executive walkarounds at Sentara Leigh. Becoming a High-Reliability Organization: Operation Advice for Hospital Leaders. Rockville, MD: Agency for Healthcare Research and Quality, 2008.
19. Gosbee J. Introduction to Human Factors Series. Jt Comm J Qual Saf 2004;30:215-19.
20. Kirwan B, Ainsworth LK. Task data collection methods. In: Kirwan B, Ainsworth LK, eds. A Guide to Task Analysis. London: Taylor &Francis, 1992:71.
21. Kirwan B, Ainsworth LK. Task data collection methods. In: Kirwan B, Ainsworth LK, eds. A Guide to Task Analysis. London: Taylor &Francis, 1992:47.
22. Patton MQ. Qualitative Research and Evaluative Methods. Thousand Oaks, CA: Sage Publications, 2002:262.
23. Colligan L, Anderson JE, Potts HW, et al. Does the process map influence the outcome of quality improvement work? A comparison of sequential flow diagram and hierarchical task analysis diagram. BMC Health Serv Res 2010;10:7.
24. Xiao Y, Schenkel S, Faraj S, et al. What whiteboards in a Trauma Center Operating Suite can teach us about emergency department communication. Ann Emerg Med 2007;50:387-95. (Pubitemid 47391508)
25. Pennathur PR, Guarrera TK, Bisantz AM, et al. Cognitive artifacts in transition: an analysis of information content changes between manual and electronic patient tracking systems. Human Factors and Ergonomics Society Proceedings. Vol. 52. HFES 2008:4.
26. Wears R, Perry S, Wilson S, et al. Emergency department status boards: user-evolved artefacts for inter and intra group coordination. Cognit Tech Work 2007;9:163-70.
27. Ebright P, Patterson ES, Saleem J. RN stacking: cognitive workflow management process with implications for patient safety and quality care. 33rd Annual research Conference of the Midwest nursing research Society. Minneapolis, USA: Midwest Nursing Research Society, 2009.
28. Patterson ES, Ebright PR, Saleem JJ. Investigating stacking: how do registered nurses prioritize their activities in real-time? Int J Ind Erg 2011;41:389-93.
29. Boehm-Davis D, Remington R. Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strategies. Accid Anal Prev 2009;41:1124-9.
30. Norman DA. Design of Everyday Things. New York: Basic Books, 2002:187-219.
31. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006;15:39-43. (Pubitemid 43275524)
32. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002;11:15-18. (Pubitemid 35265296)