Current Work
Distraction and Interruption in Anaesthetic Practice

Background

The anaesthetic work environment is often a complex and dynamic place; a range of tasks both mental and practical are required to be undertaken simulataneously1. When life and death decisions are made in these conditions, human error, equipment failure and organisational disturbances can lead to disastrous consequences2-4. Thus, patient safety is becoming of increasing interest to the medical profession5-7. A recent critical incident analysis in anaesthesia found, perhaps unsurprisingly, that human error was involved in 82% of preventable adverse events8; with distraction related to an estimated 43% of medical errors9. These statistics indicated the need for studying the work, tools and the environment of the anaesthetist to improve patient safety.

Concentration and attention to detail are prerequisites of safe anaesthetic practice, therefore it is imperative that we learn and understand how their breakdown, in a busy high pressured environment, leads to medical errors.

Research has been conducted into the frequency, cause and effect of distraction and interruption in the operating theatre for surgical teams7,10-12 but has yet to be studied for the anaesthetist.

Aims and Objectives

1) To measure the timing and frequency of distractions and interruptions to the anaesthetist

2) To explore the cause and effect of the relationships between concentration, distraction, interruption and error

3) To see if there are any strategies already in place which anaesthetists use to reduce distraction and interruption

4) To refine and develop the methodology for studying this topic to inform a future larger study

Methods

The research project will run over a four month period.

Phase 1 – Preparation (Approximately 4 weeks)

All anaesthetists at the Royal Lancaster Infirmary will receive a copy of the research proposal and the participant information sheet and will be contacted for consent to a structured interview and for observational work to be conducted in the theatre session.

Structured interviews will be held with anaesthetists to discover what types of distraction/interruptions are encountered and at which point in the anaesthetic process anaesthetists believe them to be most hazardous to patient safety. Any existing strategies that are used to reduce distraction and interruption will be explored. The structured interviews will be approximately 15 minutes in duration.

An anaesthetic task recording sheet will be produced to assist in data collection. Categories identified from previous research11 to record event sources include:

1. Telephone ringing

2. Bleeps/Pagers

3. An action to the radio

4. Case irrelevant communication

5. Communication difficulties

6. External staff

7. Equipment – unavailable or failing

8. Work environment

9. Procedural

10. Movement in front of the anaesthetic machine

Operating theatre managers will also receive a copy of the research proposal.

Phase 2 – Data Collection (Approximately 5 Weeks)

Using the anaesthetic task recording sheet, stopwatch, pen and paper the observational work will be conducted by one observer in the anaesthetic room and operating theatre to record the frequency, timing, cause and effect of distractions or interruptions on the anaesthetist. Data collection will commence when the anaesthetist enters the anaesthetic room and will finish once the anaesthetist leaves recovery. To enable comparisons between studies definitions of distraction and interruption are to be taken from previous research10,11. Distraction being defined as a break in attention, observed by orientating away from a task or verbal response and an interruption defined a break in task activity, observed by the cessation of a task.

Fifty operations will be observed. The observations will occur during both morning and afternoon sessions and of varied surgical lists. A proposed distribution of specialties is as follows:

Vascular (6)

Orthopaedic (6)

General Surgical (6)

Obstetrics (6)

Gynaecology (6)

Urology (6)

Emergency (7)

Day case (7)

The total of 50 anaesthetics was chosen based on previous research11,12 and to take into account the time frame assigned to data collection.

Phase 3 – Data Management and Analysis (Approximately 3 Weeks)

The frequency, timing, cause and effect of distractions and interruptions can then be classified and statistically analysed.

No patient details will be collected.

Phase 4 – Write Up (Approximately 3 Weeks)

Phase 5 – Dissemination and Outcome

The results of this research will be presented at a local meeting for the anaesthetic department and at the North West regional meeting for academic trainees. It is hoped that this project will form a basis for further research into distractions and interruptions in anaesthetic practice, which could lead to publication in a peer-reviewed journal.

Once the frequency, cause and effect of distractions and interruptions are known a strategy for managing these could be put into place for further evaluation. This could include practical solutions and recommendations for further training of theatre staff and the re-organising of workflow.

Ethical Issues

The research project is subject to trust and NHS Research Ethics Committee approval.

Resource Requirements

The co-operation and permission of all clinical staff who work in theatres will be required. We have already secured the co-operation of the members of the Department of Anaesthesia at the Royal Lancaster Infirmary.

References

1. Leedal JM, Smith AF. Methodological approaches to anaesthetists’ workload in the operating theatre. British Journal of Anaesthesia 2005;94(6):702-709

2. Aggarwal R, Undre S, Moorthy K, Vincent C, Darzi A. The simulated operating theatre: comprehensive training for surgical teams. Quality and Safety in Health Care 2004;13(Supplement 1):i27-i32

3. Manser T, Wehner T. Analysing Action Sequences: Variations in Action Density in the Administration of Anaesthesia. Cognition, Technology and Work 2002;4:71-81

4. Stone R, McCloy R. Ergonomics in medicine and surgery. British Medical Journal 2004;328:1115-1118

5. Hales BM, Pronovost PJ. The Checklist-a tool for error management and performance improvement. Journal of Critical Care 2006;21:231-235

6. Manser T, Wehner T, Rall M. Anaesthetists at work: analysing the operational composition of action sequences 2002. 4th International Conference on Methods and Techniques in Behavioural Research Amsterdam. [www.noldus.com/events/mb2002/program/abstracts/manser.html (accessed 19th April 2009)]

7. Karanfil L, Bahner J, Most R. Creating a patient-safe environment in a perioperative setting. Association of periOperative Registered Nurses 2005;81(1);168-176

8. Bogner S. Human Error in Medicine. New Jersey: Lawrence Erlbaum Associates 1994

9. Collins S, Currie L, Bakkens S, Climino JJ. Interruptions during the use of a CPOE system for MICU rounds. American Medical Informatics Association Annual Symposium Proceeding Archive 2006:2006;895

10. Healey AN, Primus CP, Koutantji M. Quantifying distraction and interruption in urological surgery. Quality and Safety in Health Care 2007;16:135-139

11. Healey AN, Sevdalis N, Vincent CA. Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics 2006;49(5-6);589-604

12. Sevdalis N, Healey AN, Vincent CA. Distracting communications in the operating theatre. Journal of Evaluation in Clinical Practice 2007;13(3):390-394

 
Research into practice
As a Research Unit, presentations to academic audiences and publications in peer-reviewed journals are important to us, but we also want to make a difference in practice. Thus we also intend to exploit to the full the links between research and practice which this NHS-based arrangement allows, as we have already done so successfully for previous projects.
 
Emotions, gender and patient safety
Despite the fact that there is a growing literature on gender and emotions both in psychology and other disciplines, there is very limited work on any possible links the debate might have to patient safety. Dr Arfanis has been involved in the study of gender and emotions -particularly in relation to masculinity- and there are plans to expand on his previous work to include issues connected to patient safety. More particularly, work is scheduled that will explore whether patient safety is enhanced when a male doctor is able to express his emotions and feelings both at home and at work, rather than adopt a ‘stiff upper lip’ approach.
 
Methods in patient safety
The science of patient safety is relatively young, and there are many unanswered questions for instance, about the best methods to use and how the need to improve patient safety can be squared with the requirements for ‘high level’ evidence to support new interventions in the modern NHS.
 
Situated learning in medical work: case studies in patient safety.
This is the focus of a Collaborative Award in Science and Engineering (CASE) studentship funded by the Economic and Social Research Council and the University Hospitals of Morecambe Bay NHS Trust. Our PhD student, Irene Swarbrick, is being co-supervised by Professor Andrew Smith and Dr Maggie Mort of the Institute for Health Research at Lancaster University. Using an ethnographic approach drawing on theories of the sociology of science and technology, observational data are being collected in Accident and Emergency, Radiology and within the Clinical Governance team. The work is illuminating how practitioners learn to make sense of medical images and how they make sense of incidents that affect patient safety. We expect that the findings will help shape the training of junior doctors and other professionals.
 
Beyond numbers: incident reporting and analysis
Incident reporting and analysis is a key tool in the promotion of patient safety. However, there are many limiting factors. For such systems to be effective, staff must report incidents in the first place and there must be feedback and learning if mistakes are not to be repeated.

Drs Jon Arnot-Smith and Chris Cassidy are working on this area, in conjunction with Professor Smith. We are working with the UK National Patient Safety Agency on this programme. The Agency has provided us with data from the National Reporting and Learning System (NRLS), and we are pursuing two lines of enquiry. First, we are making an assessment of the material contained in the database and the way incidents are classified and coded. Second, we are extracting data of relevance to anaesthetic practice and taking responsibility for feeding this back into professional networks. We are starting to examine the learning on aspects such as equipment failure, problems with the patient’s airway, regional anaesthesia and the use of medicines for neuromuscular blockade. Second, we are performing a comparative epidemiological mapping of incident reporting through various mechanisms, to establish the relative importance of ‘educational’ discussion of problems within anaesthetic departments compared with formal reporting through Trust-based schemes and the NRLS.
 
Measurement and monitoring
In an innovative interdisciplinary collaboration, this will be co-supervised by Professors Peter Diggle from the Department of Medicine and Mike Pidd in Management Science, both at Lancaster University. We will have two PhD students in this programme. The first, Lisha Deng, started in October 2007 and will work on the statistical aspects of time and spatial series analysis of adverse incident data. The second is due to join the Unit in September 2008 and will work more on the organisational aspects of how performance data relating to safety are conceptualised, collected and interpreted at an organisational level.
 
Risk, safety and identity

 

In our view, patient safety can only ‘happen’ when it  exists in the minds of those at the point of delivering care: managers, clinicians, patients and carers. Thus part of our work is to explore how risk and safety are understood at this ‘low level’ organisational space  and how to help those responsible for constructing safe care for patients do so effectively.


This study looks at how notions of risk and safety become learned as part of professional training, and how they are balanced in the day-to-day work of staff, managers and patients against such competing influences as quality of care, patient comfort and dignity, organisational efficiency, professional values etc. This is an interview-based investigation, conducted by Dr Konstantinos Arfanis and James Shillito. How notions of risk and identity shape safety behaviours such as checking, and the role of ‘non-clinical’ staff such as porters, ward clerks and records staff, in the maintainence of safe patient care, are also issues that we aim to explore.

1 Risk,

Background 

Industrial safety systems thinking has recently been promoted widely in healthcare as a means of improving the safety of care (Kohn et al. 1999).  This reflects the increasing pressure from healthcare professionals and service users alike for higher quality care and the avoidance of unnecessary risk.  However, there are important differences between the two settings. In particular, healthcare staff may be more likely to see themselves as belonging to a particular professional group than as ‘equivalent actors’ within a safety system (Amalberti 2005). Key to this is the notion of personal identity. The formation, understanding and expression of identity (Brown, 1986).and the part played in this by our relations to others (Markus & Kitayama, 1991,Hatch & Schultz, 2004) are central themes in social psychology. There is, however, very little work on professional identity in healthcare workers either in general or specifically on the relationship between identity and notions of risk and safety. Identity influences an individual’s understanding of his/her (professional) environment, including the notions of risk and safety (Lupton, 1999). As McDonald et al (2005) argue  

‘individuals perceive and interpret risk in the context of their place in a society whose particular social forms influence what they come to perceive as risks. The implication of this approach is that challenges to risk perception represent not an appeal to individuals to adopt an alternative cognitive perspective, but a threat to existing forms of social order and, by implication, the shared values and beliefs which underpin those.’ (pp 399-400) 

Personality, culture and professional identity, and how they relate to risk and safety is at the centre of our scrutiny. Most work has been in the operating theatre setting, (McDonald et all 2005). In handover communication between anaesthetists and nurses in the postoperative recovery room (Smith et al 2007) there were informally-negotiated practices which demonstrated different and sometimes conflicting conceptions of what each professional groups considered as within the boundaries of safe practice. In MacDonald’s work, standardisation and the use of protocols in the name of promoting safety appeared to bolster managerial identities and seemed to be a key component of professional identity in nursing. In contrast, such developments appeared to threaten the medical identity. However, how these attitudes come about, how they are conceptualised within individual professional identities and what consequences they might have, have not been explored.

Aims and objectives 

This project focuses on the relationship between identity and risk in more detail in a number of contrasting groups of staff in acute care settings. Our specific research questions are:  

1  To what extent are notions of risk and safety part of the way healthcare practitioners are thinking in order to guide their day-to-day work? How are these ways of thinking learned and/or adopted?

2  If patient safety  is not included in these ways of thinking mentioned above, what is their relation to potentially conflicting aims of one’s daily routine – for instance, how do they relate to patient comfort, quality of care, efficiency, patient autonomy etc?

3  If  we assume that some practitioners are more tuned to safety problems within their work routines than others, could professional status and/or training account for such a phenomenon?

4 Are there benefits and rewards to having a higher sensitivity to risk and safety in the workplace, and if so what are they?  

Relevant literature 

Amalberti R, Auroy Y,  Barach P, Berwick DM. Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine 2005; 142: 756-64. 

Brown, R. (c1986) Social psychology, second edition, New York: Free Press; London:Collier Macmillan 

Glaser, B. G. & Strauss, A. (1967) The Discovery of Grounded Theory: Strategies forQualitative Research. Chicago, IL: Aldine Publishing Co. 

Hatch, M. J. and Schultz, M. (2003) Bringing the corporation into corporatebranding, European Journal of Marketing, 37 (7/8), p. 1041-1064 

Kohn L, Corrigan J, Donaldson ME (1999) ‘To er is human’ National Academy Press, Washington, DC 

Leape LL (1994) Error in Medicine. Journal of the American Medical Association 272: 1851-1857 

Lupton, D. (1999) Risk New York: Routledge 

Markus, H. and Kitayama, S. (1991) Culture and the self: implications for cognition, emotion and motivation, Psychological review, 98, p. 224-253 

McDonald R, Waring J, Harrison S. (2005) ‘Balancing risk, that is my life’: The politics of risk in a hospital operating theatre department. Health Risk & Society 7:4, 397 

McDonald R,  Waring J,  Harrison S, Boaden R, Walshe K, Parker D. (2005) An Ethnographic Study of Threats to Patient Safety in the Operating Theatre.  Available at: http://www.pcpoh.bham.ac.uk/publichealth/psrp/Pdf/Harrison_Final_Final_Report_Dec_2005.pdf  

Smith AF, Pope C, Goodwin D, Mort M.’ Contested conversations’: an observational study of patient handovers in the recovery room. Acta Anaesthesiologica Scandinavica 2007; 51(Suppl 118): 18-19 

Triandis, H.C., Bontempo, R., Villareal, M., Asai, M. and Lucca, N. (1988) Individualism and collectivism: cross cultural perspectives on self-in-grouprelationships, Journal of personality and Social Psychology, 54 (2), p. 323-338 

Wilson J, Woods I, Fawcett J et al (1999) Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. British  Med J 318: 1099–103 

 

 
 

University Hospitals of Morecambe Bay