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Understanding the Types and Effects of Clinical Interruptions and Distractions Recorded in a Multihospital Patient Safety Reporting System

Kellogg, Kathryn M. MD, MPH*†; Puthumana, Joseph S. BA*; Fong, Allan MS*; Adams, Katharine T. BA*; Ratwani, Raj M. PhD*

doi: 10.1097/PTS.0000000000000513
Original Article: PDF Only

Objectives Interruptions and distractions have been shown to be a frequent occurrence across health care and have been linked to negative outcomes that create potential patient safety risks. Although observational studies have catalogued interruption frequency and source, the impact of an interruption is difficult to observe. We analyzed patient safety event (PSE) reports related to interruptions to identify clinical processes reported to be frequently interrupted and the reported outcomes of those interruptions.

Methods We retrospectively analyzed PSE reports entered by frontline staff between January 2013 and January 2016. Of 79,428 total PSEs entered, 220 reports were identified using keyword matching and subsequent manual review as being directly related to a clinical interruption. Categories were developed to identify the cause of the interruption, task being interrupted, and the result of the interruption. Percentages were calculated.

Results Nurses were most often reported to be interrupted in the PSEs (50%). General distractions (43.2%) or high workload (18.6%) were most commonly noted to interrupt the individual’s work. The interrupted activity was most often a medication task (50.9%), frequently in the administration phase (24.1%), or the ordering phase (16.8%). The most common medication error was wrong dose administration (14.4% of total medication-related errors). Laboratory processes were reported to be disturbed by interruptions in 22.7% of reports, and this frequently resulted in mislabeling of specimens (75% of laboratory-related errors).

Conclusions This retrospective review of PSE reports involving interruptions of clinical activities reveals that interruptions affect a variety of aspects of patient care and can help to guide future work on interruption management.

From the *National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health; and

Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, District of Columbia.

Correspondence: Kathryn M. Kellogg, MD, MPH, 3007 Tilden St. NW, Suite 7 M, Washington DC, 20008 (e-mail:

Conflict of Interest: The authors disclose no conflict of interest.

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