Tobias Grundgeiger

Interruptions in healthcare: Theoretical views

BACKGROUND Researchers in healthcare have begun to investigate interruptions extensively, given evidence for the adverse effects of work interruptions in other domains and given the highly interruptive hospital environment. In this paper, we reviewed literature on interruptions in critical care and medication dispensing settings in search of evidence for a relationship between interruptions and adverse events. METHODS The literature search included the databases MEDLINE, CINAHL+Pre CINHAL, Health Sources: Nursing Academic Edition, EMBASE, PsycINFO, ISI Web of Science and Ergonomics Abstracts. The paper titles and abstracts were subsequently reviewed. After the initial search, we reviewed paper titles and abstracts to define the subset for review. RESULTS We currently lack evidence in healthcare of the extent to which interruptions lead to adverse effects. The lack of evidence may be due to the descriptive rather than causal nature of most studies, the lack of theory motivating investigations of the relationship, the fact that healthcare is a complex and varied domain, and inadequate conceptualizations of accident aetiology. We identify two recent accident theories in which the relationship between activity and medical errors is complex, indicating that even when it is sought, causal evidence is hard to find. DISCUSSION Future research on interruptions in healthcare settings should focus on the following. First, prospective memory research and distributed cognition can provide a theoretical background for understanding the impact of interruptions and so could provide guidance for future empirical research on interruptions and the planning of actions in healthcare. Second, studying how interruptions are successfully rather than unsuccessfully overcome may better help us understand their effects. Third, because interruptions almost always have positive and adverse effects, more appropriate dependent variables could be chosen.

Interruptions and blood transfusion checks: lessons from the simulated operating room.

Interruptions occur frequently in the operating room with both positive and negative consequences. Interruptions can distract anesthesiologists from safety-critical tasks, such as the pretransfusion blood check. In a simulated operating room, 12 anesthesiologists requested blood as part of a “bleeding patient” scenario. They were distracted while their assistant accepted delivery of the product and began transfusing without performing the standard check. Anesthesiologists who immediately engaged with the interruption failed to notice the omission, whereas those who rejected or deferred the interruption all noted and remedied the omitted check (P < 0.05). We discuss the role of displays and strategies on safety.

The role of inhibitory processes in part-list cuing

Providing a subset of studied items as retrieval cues can have detrimental effects on recall of the remaining items. In 2 experiments, the authors examined such part-list cuing impairment in a repeated testing situation. Participants studied exemplars from several semantic categories and were given 2 successive cued-recall tests separated by a distractor task of several minutes. Part-list cues were provided in the 1st test but not the 2nd. Noncue item recall was tested with the studied category cues (same probes) in the 1st test, but novel, unstudied retrieval cues (independent probes) in the 2nd test. The authors found detrimental effects of part-list cues in both the 1st (same-probe) test and the 2nd (independent-probe) test. These results show that part-list cuing impairment can be lasting and is not eliminated with independent probes. The findings support the view that the impairment was caused by retrieval inhibition.

Effects of sleep deprivation on prospective memory

Sleep deprivation reduces cognitive performance; however, its effects on prospective memory (remembering to perform intended actions) are unknown. One view suggests that effects of sleep deprivation are limited to tasks associated with prefrontal functioning. An alternative view suggests a global, unspecific effect on human cognition, which should affect a variety of cognitive tasks. We investigated the impact of sleep deprivation (25 hours of sleep deprivation vs. no sleep deprivation) on prospective-memory performance in more resource-demanding and less resource-demanding prospective-memory tasks. Performance was lower after sleep deprivation and with a more resource-demanding prospective-memory task, but these factors did not interact. These results support the view that sleep deprivation affects cognition more globally and demonstrate that sleep deprivation increases failures to carry out intended actions, which may have severe consequences in safety-critical situations.

How do interruptions affect clinician performance in healthcare? Negotiating fidelity, control, and potential generalizability in the search for answers

Interruptions and distractions are a feature of work in most complex sociotechnical systems in which people must handle multiple threads of work. Over the last 10-15 years there has been a crescendo of reviews and investigations into the impact that interruptions and distractions have on safety-critical aspects of healthcare work, such as medication administration, but findings are still inconclusive. Despite this, many healthcare communities have taken steps to reduce interruptions and distractions in safety-critical work tasks, a step that will usually do no harm but that may have unintended consequences. Investigations with a higher yield of certainty would provide better evidence and better guidance to healthcare communities. In this viewpoint paper we survey some key papers reporting investigations of interruptions and distractions in the field, in simulators, and in the laboratory. We also survey reports of field interventions aimed at minimizing interruptions and distractions with the intention of improving the safety of medication administration and other safety-critical healthcare tasks. To analyse the papers adopting each form of investigation, we use the three dimensions of fidelity, formal control exercised, and the potential generalizability to the field. We argue that studies of interruptions and distractions outside the healthcare clinical context, but intended to generalize to it, should become more formally representative of the cognitive context of healthcare work. Research would be improved if investigators undertook programs of studies that successively achieve fidelity, control, and potential generalizability, or if they strengthened the design of individual studies. Interruptions in healthcare are studied in the field, simulators, and laboratory.The goal is to test whether interruptions can harm clinicians and their patients.Methods used vary in fidelity, control exercised, and potential generalizability.Studies with low fidelity should be more representative of healthcare work.Research would be improved by programs of studies and improving individual studies.

Obstacles to research on the effects of interruptions in healthcare

The authors of The Institute of Medicine report ‘To Err is Human’ concluded that interruptions can contribute to medical errors.1 Given this risk, healthcare researchers have generally, and often solely, viewed interruptions as obstacles to work—as factors that thwart progress, create stress, increase workload, interfere with memory for current and future tasks2 ,3 and harm efficiency, productivity and safety.4 For example, researchers reported a positive association between interruptions and errors.5 A contrasting view is to see interruptions as promoting safety and high-quality patient care. From this view, interruptions function as interventions ,6–8 such as a call to cease or change work if the interruptee is potentially committing an error.9 Other industries encourage interruptions for that reason. Many researchers investigating interruptions in healthcare cite the sterile cockpit principle10 as a rationale for reducing interruptions—but it is less often noted that copilots are trained to speak up with safety concerns even if it means interrupting a senior pilots work.11 These different views on studying interruptions have made it difficult to draw conclusions from the research. Granted, diverse perspectives and methods can generate a greater variety of ideas and solutions than single perspectives and methods.12 However, such diversity also makes it more difficult to compile and compare research results or identify critical research questions. The present paper draws attention to three obstacles to research on the effects of interruptions that arise from differing views and methods: definitions, processes and data collection. We discuss possible solutions that may lead us to a better understanding of the effects of interruptions and to a multidisciplinary view on the effects of interruptions in healthcare. The burgeoning literature on interruptions in healthcare offers multiple definitions for what an interruption is.4 ,13 For instance, in her seminal …

Distributed Prospective Memory: An Approach to Understanding how Nurses Remember Tasks

Peoples ability to execute future intentions, or their prospective memory (PM), is a critical aspect of cognitive work because failures can have adverse outcomes. Most research to date deals with unaided prospective memory performance outside a healthcare context. We report results from a field study investigating PM performance of intensive care nurses. Concepts from distributed cognition help to identify how nurses use physical properties of their working environment to manage PM demands. Results show that (1) PM demands can be classified using a taxonomy from aviation and (2) nurses are supported by and use properties of the environment to manage PM demands. Focusing on distributed support for prospective memory lets us study prospective memory in rich work contexts. The results inform health information system and device design and professional education.

Noncompetitive retrieval practice causes retrieval-induced forgetting in cued recall but not in recognition

Retrieving a subset of learned items can lead to the forgetting of related items. Such retrieval-induced forgetting (RIF) can be explained by the inhibition of irrelevant items in order to overcome retrieval competition when the target item is retrieved. According to the retrieval inhibition account, such retrieval competition is a necessary condition for RIF. However, research has indicated that noncompetitive retrieval practice can also cause RIF by strengthening cue–item associations. According to the strength-dependent competition account, the strengthened items interfere with the retrieval of weaker items, resulting in impaired recall of weaker items in the final memory test. The aim of this study was to replicate RIF caused by noncompetitive retrieval practice and to determine whether this forgetting is also observed in recognition tests. In the context of RIF, it has been assumed that recognition tests circumvent interference and, therefore, should not be sensitive to forgetting due to strength-dependent competition. However, this has not been empirically tested, and it has been suggested that participants may reinstate learned cues as retrieval aids during the final test. In the present experiments, competitive practice or noncompetitive practice was followed by either final cued-recall tests or recognition tests. In cued-recall tests, RIF was observed in both competitive and noncompetitive conditions. However, in recognition tests, RIF was observed only in the competitive condition and was absent in the noncompetitive condition. The result underscores the contribution of strength-dependent competition to RIF. However, recognition tests seem to be a reliable way of distinguishing between RIF due to retrieval inhibition or strength-dependent competition.

Evaluating the Effectiveness of a Memory Aid System

Background: The ability to remember future intentions is compromised in both healthy and cognitively impaired older adults. Assistive technology provides older adults with promising solutions to cope with this age-related problem. However, the effectiveness and efficiency of such systems as memory aids is seldom evaluated in controlled, randomized trials. Objectives: We evaluated the effectiveness of a memory aid system, the InBad (engl. InBath), for bathroom-related daily care. Conceptually, the InBad learns user behavior patterns and detects deviations from the learned pattern in order to notify the user of a forgotten task. Methods: We simulated a challenging morning routine consisting of 22 bathroom activities with a sample of 60 healthy older adults. Participants were randomly assigned to three groups: (1) ‘no memory support’, i.e. participants received no support at all, (2) ‘list support’, i.e. participants could retrieve a list of all activities, and (3) ‘system support’, i.e. participants received prompts for specific activities that had not yet been executed. Results: Both support groups executed significantly more activities compared to the ‘no support’ group. In addition, system support resulted in significantly better performance compared to list support with no significant differences between the two groups in overall task duration. Conclusion: The assistive support system was the most effective and efficient memory aid. The results suggest that assistive technology has the potential to enable older adults to remain safe and independent in their own home.

Training students to use syringe pumps: an experimental comparison of e-learning and classroom training.

Abstract The inadequate use of syringe pumps can jeopardize patient safety, and syringe pump trainings are conducted to manage this risk. A critical step in this risk management process is the learning success of trainees. In the present paper, we compared an e-learning approach with standard classroom training in learning success effectives, trainees’ opinion on the trainings, and investigated the relation between technological affinity and learning success. The results showed that e-learning was as effective as classroom training but nursing students’ confidence in using the pump and satisfaction with the training was decreased for e-learning compared with classroom training. We discuss the results in context of the nursing e-learning literature. Finally, we discuss the literature for risk identification, risk analysis, risk treatment, and risk monitoring and control in the context of syringe pump training and add the lessons learned from the evaluated e-learning program.