In my world, people are either sick or not. If they are sick, I try my best to facilitate their health. If I cannot facilitate their health, it is not because I myself am fallible. It is because someone somewhere designed something in a manner that is impeding my ability to do my job, and that person must be blamed.
The leukemia patient assessment unit where I work as a nurse practitioner was busy, and my desk was situated at the entrance door to the clinic. Hundreds of people walked through that door a day. They would stop at my desk to chat, ask directions, and seek advice. Many would even ask where I got my latte. I like to chat. However, when you are trying to assess up to 40 patients a day and order or adjust pharmacotherapeutic interventions, it is not a good idea to chat. Chatting leads to distractions, which lead to missed information, which leads to error and omissions, which lead to patient injury.
The US Pharmacopeia has suggested that up to 43 percent of medication errors could be attributed to distractions. So I did what most seasoned oncology nurses would do. I complained to the chief operating officer of the hospital. "Brian, this is not a good setup," I said. "Someone has decided that my desk should be here, but I'm telling you -- I feel like a department store greeter. This is unsafe. The interruptions are impeding my ability to deliver safe patient care. Can I get a quieter work space?"
To which Brian responded, "Do the other nurses feel the same way?" I've noticed those senior admin types often use that strategy -- answer questions with a question until eventually, you've basically answered your own question. However, that particular question did make me wonder how many of the other nurses felt that interruptions were causing a work hazard and (more importantly) if they actually were. I set about to elicit some support for a proposed work space move. What I found is that most people were feeling the same way. Everyone wanted a quieter work space. Well, I knew that wouldn't happen, so I tried to understand what changes we could make to improve the environment and improve patient safety.
A colleague and I decided it might be an excellent topic to research, and so we created a research proposal to examine the effects of interruptions on patient safety in an oncology setting. Soon after submitting the proposal, we received a response from the funding agency letting us know that a similar proposal had been submitted by the Human Factors Interest Group from one of our other organizational sites. My colleague and I looked at the response and simultaneously responded with "The human who?"
We set about to find this group and determine if it were worthy of a partnership with us. After all, we were the nurses who lived this every day. We knew what we were talking about, and we were pretty certain that this group was an impostor of some sort. What could this group know?
Most of the people in this group were engineers -- not even nurses. But as it turns out, they knew plenty. They did not know what we knew, and we definitely did not know what they knew. They knew the process of applying research to clinical problems associated with factors that were under the control of humans, and they used this methodology to identify causes of error. They knew how to observe, collate, analyze, and present the clinical data in a way that made sense from a research perspective. We knew how to describe the multifaceted choreography of clinical care delivery in the complex world of oncology care. Without us, they would be lost. Without them, our voices would be lost. We needed help to dissect our observations and report them in a way that made sense to the non-nurses -- the administrators, program planners, and policy developers.
What we found is that interruptions were impeding the delivery of safe care. We studied ideas such as:
- Creating a small, closed-in area where nurses could check and review the medications with the original order
- Putting signs on the chemo pumps that said, "Please don't talk to me right now, I am in the process of medication delivery. It is unsafe to interrupt me at this time."
- Having medication delivery nurses wear a bright colored lab coat or vest to signal that they were in the middle of a very delicate and dangerous task
Did these things help? Yes, they did. Interruptions were decreased. Did I get my desk moved? Well, no, but I was content with the overall outcome of improved patient safety. In the process, I also connected with the Human Factors Interest Group, an incredibly knowledgeable team of people who understand and can deconstruct complex human processes to identify problem areas and opportunities for improved patient safety.