Community pharmacies are busy environments that are prone to distractions and interruptions. Patients can walk in at any time, telephones and fax machines go off, alarms ping from computers, and staff interrupt themselves and others for a broad range of reasons. While the rate of interruptions and distractions in community pharmacies varies, one study found that interruptions ranged from seven to thirteen per hour[1].
Frequent interruptions can lead to increased workload and medication incidents.
When safety-critical work such as order entry or verification, compounding, or administering vaccines are interrupted, the risk of patient harm due to a medication incident is increased. A study of hospital nurses performing drug administration revealed that each interruption increased procedural errors by 12 percent and clinical errors by 13 per cent. There is high cognitive demand that comes from frequently switching between tasks and contexts and this can over-tax or overtake our cognitive abilities.
In a community pharmacy, a pharmacist may need to spend time away from an original task (OT) such as prescription verification to complete an interrupting task (IT) such as providing patient counselling. Depending on the complexity of the IT, the time needed to complete the OT becomes longer because the working memory we use to complete the task begins to decay[2].
In other words, our minds become forgetful and tired.
Cognitive Ergonomics Tactics for Distractions and Interruptions
One of the main fields of study in human factors engineering (HFE) is cognitive ergonomics. Cognitive ergonomics recognizes the inherent cognitive limitations of human beings and applies design principles to lessen those shortcomings. HFE recognizes that simply demanding that people pay closer attention is not enough to prevent safety incidents. Rather than forcing people to adapt to a system, HFE demands that an environment or technology system be a good fit for people[3].
Eight Ways to Reduce Interruptions or Improve Lines of Defense in Your Pharmacy Using HFE Principles
1. Consider the physical design of the dispensary
Build your pharmacy with a separate room for safety-critical work such as preparing compliance packaging or methadone doses. Equip the room with a notification system to let the pharmacy know when colleagues or patients need help. This will reduce the social pressure to respond mid-task. Divided attention because of interruptions has been shown to diminish task performance.
Alternatively, move safety-critical work to a specific area away from distractions such as ringing phones.
2. Provide situation awareness to patients
There is considerable pressure to immediately respond to patients who walk up to the dispensary counter; however, divided attention can also lead to patient harm. Explain to the patient or customer that the pharmacist is completing safety-critical work that cannot be interrupted. Alternatively, place a sign near the pharmacist when they are completing safety-critical work that tells the patient that the pharmacist is completing a patient-safety critical task.
3. Provide situation awareness to pharmacy staff (create a “No Interruption Zone”)
A study on ‘No Interruption Zones’ used during medication preparation in an intensive care unit showed a 40.9 percent decrease in interruptions over a three-week period. Consider implementing a colour-coded system that alerts pharmacy staff when safety-critical work is being performed. You could use different coloured counter space or signs to indicate a task can be interrupted (green), should only be interrupted if necessary (yellow), and should not be interrupted (red). You could train your staff to use certain coloured space when working on tasks with various safety levels or implement a system in which they can change the colour-coding of their workspace depending on what sort of task they are performing.
4. Appropriately time necessary interruptions
When engaged in a well-defined or standardized process, we are more likely to make a mistake by omitting a step than we are to make a mistake within a step. This becomes more likely to occur if we are interrupted. During a safety-critical process, only stop between sub-tasks such as completing verification of a prescription or after entry of an order. All staff should avoid interruptions during the most complex part of a task[4].
5. Use checklists for safety-critical processes
Place checklists for safety-critical processes in relevant work areas and mark which step you have completed before stepping away because of an interruption. Sometimes when you know someone is waiting it can lead to rushing through your tasks. Using a checklist ensures that you complete each step and that you can return to that step at any time.
6. Ensure there is a mobile device policy in place in your pharmacy
Implement a policy that outlines appropriate use of personal mobile devices in the pharmacy. Educate staff on the patient safety risks of performing work while distracted. Treat prohibited cell phone use as an at-risk behaviour and provide coaching to promote safety.
7. Reduce frequency of alerts, alarms, and noises
Reduce the frequency of invalid, insignificant, or overly sensitive computer alerts and device alarms to ensure that only critical notifications are delivered.
8. Plan safety-critical processes for when mental resources are higher
Try to plan safety-critical tasks for when your mind is freshest, such as after a 15-minute break or first thing in the morning.
References
[1] Reddy A, Abebe E, Rivera AJ, Stone JA, Chui MA. Interruptions in community pharmacies: Frequency, sources, and mitigation strategies. Res Social Adm Pharm. 2019 Oct;15(10):1243-1250. https://pubmed.ncbi.nlm.nih.gov/30420227/
[2] Lee, John & Wickens, Christopher & Liu, Yili & Boyle, Linda. (2017). Designing for People: An introduction to human factors engineering.
[3] Vicente, K. J. (2003). The human factor: Revolutionizing the way people live with technology. Toronto: A.A. Knopf Canada
[4] Institute for Safe Medication Practices. Deflect distractions and intercept interruptions. Pharmacy Today 2013, April 1; 19(4). https://www.pharmacytoday.org/article/S1042-0991(15)31384-0/fulltext#relatedArticles
