Study Design: The nursing drug delivery process was divided into 3 segments: the processing of doctors’ orders, drug allocation, and bedside drug administration. The frequency, source, type, and outcome of interruption events during these 3 segments were observed. The interruption time and medication errors caused by interruptions were analyzed.
Methods: The structural observation method was used to observe the 3 steps of the drug delivery process. The observations were performed between 8:30 and 10:30 and between 13:30 and 14:30. Count data are described as frequency, composition ratio, and cumulative percentage. R×C contingency table, t tests, and analysis of variance were used to analyze the data.
Results: In 270 hours of observation, 3424 nursing interruptions occurred, for a mean of 12.68 interruptions per hour. The mean (SD) interruption time was 28.03 (11.01) seconds, and the total duration of drug administration interruptions was 26.65 hours, accounting for 9.87% of the total observation time. The sources of interruption events were as follows: family members, the environment, doctors, patients, colleagues, the nurses themselves, and others; of these interruptions, 2340 were low-priority events (eg, visitor inquiry, telephone call, consultation, discharge questions), accounting for 68.34%. The incidence of medication errors due to interruptions was 1.139%.
Conclusions: Nursing interruption events occur frequently, come from many sources, have complex causes, and commonly lead to negative outcomes. Interruption also has a time cost and can directly lead to medication errors.
Am J Manag Care. 2021;27(6):In Press
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Takeaway Points
Work continuity interruptions increase the time required to perform activities, reduce work efficiency, and affect nurses’ attention, leading to increases in negligence and human error, which adversely affect the quality of care and patient safety.
- Nurses must remain attentive and focused when performing activities that require concentration to avoid distractions and errors.
- Reducing the occurrence of disruptions can improve the quality of the services provided and help both patients and nurses.
- The nursing manager should provide a basis for developing strategies to prevent interruption events for quality and safety of care delivery. This will also create a good workplace environment for the protection of nurses’ occupational health.
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Nursing interruptions are interruptions encountered by nursing staff during the provision of standardized care services or external behaviors that delay actions and distract nurses’ attention.1 An interruption is an unexpected disturbance that destroys the continuity of care.2 In that they affect nurses’ attention, work continuity interruptions increase the time required to perform activities and reduce work efficiency, leading to an increase in negligence and human error. This adversely affects the quality of care and patient safety.3
Interruptions often occur during nursing work in hospitals. They occur between 2 and 23 times per hour, and nearly 90% of interruptions cause negative outcomes4 and even lead to medication errors.5 Studies have confirmed that work interruption is an important cause of errors in medication administration among nurses, and the incidence of interruption events is related to errors in medication administration.6 Therefore, nurses must remain attentive and focused when performing activities that require concentration, to avoid distractions and errors.5 Reducing the occurrence of disruptions can improve the quality of the services provided and help both patients and nurses.7-9
At present, most of the reports in the literature focus on the interruption of key links such as shift handover and medication administration process.10,11 The content of the studies is mostly about the investigation of the frequency, source, and influencing factors of nursing interruption events. The survey sites were more likely to be in the intensive care unit and accident and emergency departments, and fewer are focused on general wards.12,13 There are few reports about interruption time and priority analysis of interrupting events, and most studies do not describe the specific details of interrupting events, which limits the formulation of improvement strategies. As such, our study investigated the current status of nursing interruption events during cardiology practice and analyzed the time costs, priority of events, and factors influencing interruptions to provide a basis for developing strategies to prevent interruption events for quality and safety of care delivery.
METHODS
Objectives
The nurses’ drug delivery process involves 3 steps: processing the doctor’s prescription, drug allocation, and bedside administration. Interruption events were observed during the 3 stages of the drug delivery process in the 4 wards of the Department of Cardiology (where 3 authors work) in Shandong Provincial Hospital Affiliated to Shandong First Medical University (Jinan, Shandong, China), from September 2018 to February 2019. The nurses observed were aged 27 to 36 years and had worked as nurses for 4 to 11 years.
Measures
Interruption events were recorded using an observation record table developed by the authors, which was based on existing literature. Each observation was composed of 8 parts:
- the timing of the interruption event: during medical order processing, drug allocation, or drug administration;
- a description of the interruption event: a brief note describing the specific circumstance of the interruption event;
- interruption time: recorded in seconds;
- interruption event priority level: low priority vs high priority. Low priority refers to nonmedical needs that can be postponed and resolved later; high-priority events are those related to medical needs that need to be resolved promptly, such as the assessment and resolution of a patient’s condition, postoperative handover, and the like;
- source of the interruption event: the environment, patients, family members, doctors, colleagues, the nurses themselves, or other personnel;
- type of interruption event: intrusive, distracting, contradictory, or destructive;
- nursing interruption event outcome: positive vs negative; and
- resulting medication error/hidden danger: recorded as yes/no. If the drug error/hidden danger occurred, the specific event was recorded.
Data Collection
The researchers trained 2 clinical observers to observe the 3 steps of the nurses’ drug delivery process—processing the doctor’s orders, drug allocation, and drug administration—using structured observation. The observations were performed between 8:30 and 10:30 and between 13:30 and 14:30. The observers focused on the medical advice and medication allocation that took place at those times. Observer A recorded the specific circumstances of the interruption event, such as “urging the nurse to discharge a patient from the hospital” or “inquiring about medical insurance for immediate settlement.” Observer B used a stopwatch to record the duration of the interruption. After the completion of an event observation, the 2 observers immediately summarized the interruption and used the content analysis method to determine the source, type, outcome, and priority of the interruption event. After completing the observation record, the observers continued to the next round of clinical observation. To ensure patients’ medication safety, if a nursing medication error or a hidden danger was observed during the observation, it was pointed out or stopped on time. Additionally, observations were terminated when necessary to avoid interfering with clinical work or attending to changes in the patient’s condition, clinical quality examination, and other circumstances.
Statistics
Data were entered using SPSS 18.0 software (IBM). Count data are described as frequency, composition ratio, and cumulative percentage. R×C contingency table, t tests, and analysis of variance were used to analyze the data.
RESULTS
Status of Nursing Interruption Events
In this study, doctor’s orders, drug allocation, and drug administration were observed for a total of 96 hours, 71 hours, and 103 hours, respectively, for 270 hours of observation in all. During this time, a total of 3424 nursing interruption events occurred, at a mean of 12.68 times per hour. The relationship between the 3 segments of drug administration and the outcome distribution was statistically significant (P < .001), as shown in Table 1.
Nursing Interruption Event Duration
The mean (SD) duration of the interruption events was 28.03 (11.01) seconds, and the total interruption time was 26.65 hours, accounting for 9.87% of the total observation time (Figure 1). The variance analysis showed that the mean duration of interruption events was similar for the 3 work segments (F = 1.561; P = .210).
Interruption Events Lead to Medication Errors
During the observation period, 39medication errors/hidden dangers occurred during interruption events. No medication error occurred after a second nurse was consulted or the observer pointed out the error. The incidence of medication errors caused by nursing interruption events was 1.139% (Table 2).
Analysis of the Overall Source of Interruptions
The sources of interruptions were as follows, in order from most to least frequent: patients’ family members, the environment, doctors, patients, colleagues, the nurses themselves, and others. The specific cases in which nurses were interrupted were recorded and counted. A total of 2340 low-priority interruptions occurred (68.34%) (Figure 2). The interruption events from different sources and the proportion of low-priority events are described in detail in Table 3.
DISCUSSION
In this study, the nurses experienced a total of 3424 nursing interruption events during the 270-hour observation period, for a mean of 12.68 times per hour. This department has 36 beds and 10 on-duty nurses in total. There are 4 nurses on duty in the day shift, and 1 nurse takes care of 9 patients on average. There is only 1 nurse on duty in the night shift, who takes care of 36 patients. About 160 patients are discharged from the department every month, the bed turnover is fast, and the workload of nurses is relatively large, which may be related to the high incidence of interruptions. The frequency of interruption was moderate in the current study: Flynn et al and other retrospective studies found that the average frequency of nurse interruption events was 6.7 times per hour6; Kosits and Jones14 found that nursing interruption events occurred most frequently during the evening shift, with a mean incidence of 3.3 times per hour. Li et al15 reported that emergency and intensive care unit doctors and nurses were interrupted 23 times per hour during the implementation of clinical tasks. Huang et al16 investigated the current status of nursing interruptions during the medication process in the department of respiratory medicine, and the average frequency of nursing interruptions was 7.8 times per hour. In this study, the processing of doctors’ orders was the most frequently interrupted step, at 24.40 times per hour, whereas the least frequently interrupted step was drug allocation, at 4.06 times per hour; these findings are consistent with the trend reported by Huang et al16 (an average of 10.8 interruptions per hour during the processing of doctors’ orders, 4.2 interruptions per hour during drug allocation, and 8.5 interruptions per hour during bedside administration). The timing of interruptions is related to the current environment and workflow of the cardiology department. For example, doctors’ orders are usually processed by the nurse on duty and the in-charge nurse at the nurses’ station. The nurses’ station is a relatively open space that is subject to a large flow of people consulting with patients for various problems. Many family members congregate near the nurses’ station; in addition, the call system and department telephone are placed at the nurses’ station, which increases environmental disruptions. In contrast, drug allocation takes place in the treatment room, which is a relatively closed space; furthermore, because nonemployees are not allowed to enter the treatment room, the interruption frequency is low.
Interruptions also cost time. The mean interruption in this study lasted 28.03 seconds, and the total interruption time during nurses’ drug administration process was 26.65 hours, which accounted for 9.87% of the total observation time. At present, few studies exist on the time costs of interruptions. Li et al15 reported that the clinical staff of the emergency department spent 24% of their total working hours dealing with interruptions. Forsyth et al17 observed interruptions in 38 emergency nurse shifts; during 372.5 clinical nursing hours, 3229 interruptions lasted a median of 13.0 seconds per interruption. There was a moderate positive correlation between the number of interruptions and the increase in surgical workload (r = 0.323; P = .048), and the frequency of interruptions was thought to increase the nurses’ overall workload.
The drug delivery process is often interrupted, potentially causing medication errors, and medication errors are closely related to adverse outcomes. Interruptions may pose a significant risk to patient safety, and solid psychological evidence shows that interruptions have a devastating effect on human cognition.15 According to the activation-based goal memory model, goals have associated activation levels, just like other memory elements in the cognitive system, and cognition is directed by the most active goal retrieved at any given time. The amount of activation associated with a memory item is subject to decay, and this decay process is time-based and gradual. If the cognitive system needs to refocus attention to (or resume) an old goal, then this old goal needs to undergo a priming process to become active again. The results of this study also showed that among the types of interruption events, the intrusion type accounted for 46.00%, distraction type for 32.97%, contradictory type for 18.43%, and destructive type for 2.60%. Contradictory type events refer to the behaviors that affect an individual’s theory and expectation perception and conflict with actual work: For example, a nurse plans to distribute oral medicine to patients, but one patient refuses to take it at that time. The nurse explains and handles the situation, which delays the administration of the medicine to other patients. The outcomes of these interruptions were negative in 80.02% of the cases; only 19.98% were positive. A positive outcome means that the interruption caused a good result: for example, reminding the nurse that the wrong medication may be used, rejecting the nurse’s wrong action, or reminding the nurse that a patient’s condition has changed and needs to be treated, along with other important events. The results are consistent with previous findings. It has been reported that 19% of doctors who were interrupted failed to resume their prior work, and up to 11% of errors were caused by disturbances and distractions.7
Studies have shown that work interruption is an important cause of medication errors made by nurses.In hospital wards, interruptions of nurses’ medication administration process resulted in a 12% increase in surgical failure and a 13% increase in medication errors.15 Sassaki and Perroca used a questionnaire survey to investigate nurses’ perceptions of workflow disruptions and their impact on the professional practice environment.18 Most nurses reported that their work activities were often interrupted and that disruptions have a critical impact on work dynamics, care processes, and patient safety.18 Findings of studies done in China indicate that some adverse events in clinical nursing are caused by interruptions. Yang et al19 analyzed 335 cases of adverse nursing events and found that the primary causes were interruptions during the evaluation process; these led to inadequate patient assessment due to insufficient evaluation time. Chen et al20 showed that the entire process of nursing operations was interrupted by environmental factors and that these interruptions were the main factor leading to adverse events. In the present study, 10 medication error/safety hazard events were caused by the interruption of the drug administration process, for an incidence rate of 1.209%; this finding indicates that the interruptions of the drug delivery process were closely related to adverse outcomes.
By recording the specific situation, statistics, and summary of nursing interruptions, the main reasons for factors influencing the interruption were found. The cumulative percentage of interruptions from 3 sources—patients, the environment, and doctors—was 82.70%. Many of the interruptions, such as consulting for medical insurance reimbursement, discharge inquiries, consultation, referral procedures, and messy bed units needing to be organized, were not related to the drug administration task, which is consistent with the results of Westbrook et al.21 Although nonmedical interruptions have low priority relative to the medication administration process, they reflect patients’ personal needs. For example, the most common reason patients’ family members interrupt nurses is to ask about medical insurance issues, including referral procedures, immediate settlement processes, and the amount of medical insurance payments; however, nurses’ lack of this information results in patients’ repetitive queries and consequently more interruptions. The care manager can determine patients’ service needs by studying the causes of interruption events and developing a practical feed-forward control strategy to provide predictive services and reduce nonmedical interruptions in the medication process.
Prakash et al22 conducted simulated laboratory experiments using interventions to reduce interruptions and found that nurses’ drug volume errors and infusion pump adjustment error rates were significantly reduced, prompting managers to ensure medication safety by controlling interruption events. At the same time, studies have confirmed that efforts need to be made to both reduce unnecessary interruptions in safety-critical tasks and improve nurses’ ability to adapt to inevitable interruptions.23 Our current research attempts to classify and summarize the causes of interruptions in terms of 4 aspects—initiator, receiver, system, and process—to determine where to direct interventions for improvement: initiator interventions, recipient interventions, system improvements, or process improvements. Factors may be grouped to reduce the number of interruptions.24 Recipient interventions could “enhance the ability of nurses to respond to interruptions and deal with low-priority events,” improve “refusal skills,” and other measures. System improvements could start with “optimizing equipment, maintaining wires to prevent invalid alarms, [and] equipping [patient rooms] with bedside interactive systems and portable intelligent call responders.” Process improvements could involve “reconstruction of discharge processes” and improving the medical instructions that patients receive upon discharge. In short, when a nursing interruption event occurs, the nursing manager should determine the underlying reasons, optimize the service flow, and formulate control strategies from the individual level to the system level to prevent further interruption events. In future research, we will formulate a series of targeted intervention measures based on the results of this study and apply them in clinical work to evaluate whether these interventions can effectively prevent interruption, thus reducing medication errors and other negative results.
Limitations
This study has some limitations. First, it included only nurses working in Shandong Provincial Hospital, so the findings of this study may not be applicable to other hospitals. The results of this study showed that the main source of interruption is the family members of patients, whereas US research has reported that the main source of interruption is nursing staff.25-27 Nurses in China are in charge of a large number of patients, and almost all patients are accompanied by family members, so the interruptions from the family members accounted for the majority. However, the other results of this study are consistent with results of studies performed in the United States, such as the high incidence of interruptions, the time costs, and which interruptions are likely to cause medication errors. Therefore, the study’s results may be applicable to hospitals in the United States. Second, we surveyed only the current situation of interruptions and did not take any intervention measures. In the next step of research, we plan to implement some measures, such as applying for increased nurse manpower, providing predictive service for patients, reducing the incidence of “false alarm” signals by instruments and equipment, training nurses in the skills of rejection, and adding warning signs to prevent interruption. For example, the nurses can put on special clothes during medicine administration that say “do not disturb.” We will then evaluate the effects of these strategies.
CONCLUSIONS
Nurses experience a high frequency of interruptions from many sources with complicated causes. These interruptions may have negative outcomes that can increase time costs, reduce work efficiency, and increase the risk of medication errors. Although a high proportion of these interruptions are about low-priority matters, they directly reflect patients’ needs and can be avoided or reduced by predicting patients’ needs and managing them preemptively. Doing so could have a positive effect on meeting the needs of patients, reducing time wastage, and ensuring safety in medication administration. Moreover, reducing interruptions in the medication process helps reduce the risk of distraction faced by nursing staff and helps them concentrate on the medication process, thereby saving time and reducing medication errors. Thus, the care manager should optimize the service process and formulate control strategies from the individual level to the system level to prevent interruption events from occurring further.
Author Affiliations: Department of Cardiology (WW, LJ, WH) and Outpatient Department (ZL), Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, China; School of Nursing, Shandong University (XZ), Shandong, China.
Source of Funding: This study was supported by Projects of Medical and Health Technology Development Program in Shandong Province (No. 2018WS270), Key Research and Development Project of Shandong Province (No. 2016WSB01058), and Jinan Medical Technology Innovation Program (No. 201907042).
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (WW, XZ, ZL, WH); acquisition of data (WW, LJ, XZ); analysis and interpretation of data (LJ, XZ); drafting of the manuscript (WW, WH); critical revision of the manuscript for important intellectual content (WW, LJ, WH); statistical analysis (WW, LJ, XZ); provision of patients or study materials (WW, ZL, WH); administrative, technical, or logistic support (ZL, WH); and supervision (ZL).
Address Correspondence to: Weizhong Han, MD, Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Rd, Ji’nan, Shandong, China 250021. Email: hanweizhong003@163.com.
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