March 2010 Volume 36 Number 3 The Joint Commission Journal on Quality and Patient Safety Interruptions and Multitasking in Nursing Care Adverse Events 126 N ursing care requires complex thinking processes, includ- ing making inferences and synthesizing information. 1 The environment surrounding registered nurses (RNs) has been described as fast-paced and unpredictable, 2 and nurses’ cognitive load as exceptionally heavy. 3,4 A study showed that nurses, moving among multiple patients with changing clinical situations, engage in a recursive cognitive process that uses inductive and deductive cognitive skills. 3 Interruptions and multitasking are felt to predispose indi- viduals to making errors. 5,6 In high-risk industries, such as nuclear power plants and aviation, interruptions are a known human factor that contribute to errors and catastrophic events. 7,8 Interruptions and multitasking are seen as particular sources of concern in that they negatively affect an individual’s working memory, which is limited in its capacity and transient in nature. The problem with working memory is that when items are stored temporarily, they can easily be bumped out by more information coming in or lost completely. 9 Interruptions and multitasking have been found to impose heavy cognitive loads on individuals, which swamp attentional resources and result in perceptual and other errors. 5,10–12 Previous Studies Studies of interruptions and multitasking in health care are lim- ited, and most have focused on physicians, 13–18 with the few including nurses limited to the emergency department (ED) and ICU units. 19,20 Only a few studies measured the relationship between interruptions and/or multitasking and errors. There have been three published reports of nurse interrup- tions in acute care inpatient settings. Ebright et al. found that RNs were interrupted 6.3 times per hour, 2 while Potter et al., using both an RN and a human factors engineer (HFE) observ- er, uncovered 5.9 per hour (HFE) and 3.4 per hour (RN). 21 A third study, conducted by McGillis-Hall et al., reported 14 interruptions per hour. 22 That study was the only one of the three that dealt with patient safety, but the authors did not actually record observed errors. They coded events if they Article-at-a-Glance Background: The environment surrounding registered nurses (RNs) has been described as fast-paced and unpre- dictable, and nurses’ cognitive load as exceptionally heavy. Studies of interruptions and multitasking in health care are limited, and most have focused on physicians. The extent and type of interruptions and multitasking of nurses, as well as patient errors, were studied using a natural-setting obser- vational field design. The study was conducted in seven patient care units in two Midwestern hospitals—an academ- ic medical center and a community-based teaching hospital. Methods: A total of 35 nurses were observed for four-hour periods of time by experienced clinical nurses, who under- went training until they reached an interrater reliability of 0.90. Findings: In the 36 RN observations (total, 136 hours) 3,441 events were captured. There were a total of 1,354 interruptions, 46 hours of multitasking, and 200 errors. Nurses were interrupted 10 times per hour, or 1 interrup- tion per 6 minutes. However, RNs in one of the hospitals had significantly more interruptions—1 interruption every 4 1/2 minutes in Hospital 1 (versus 1 every 13.3 minutes in Hospital 2). Nurses were observed to be multitasking 34% of the time (range, 23%–41%). Overall, the error rate was 1.5 per hour (1.02 per hour in Hospital 1 and 1.89 per hour in Hospital 2). Although there was no significant rela- tionship between interruptions, multitasking, and patient errors, the results of this study show that nurses’ work envi- ronment is complex and error prone. Discussion: RNs observed in both hospitals and on all patient care units experienced a high level of discontinuity in the execution of their work. Although nurses manage interruptions and multitasking well, the potential for errors is present, and strategies to decrease interruptions are needed. Beatrice J. Kalisch, R.N., Ph.D.; Michelle Aebersold, R.N., Ph.D. Copyright 2010 Joint Commission on Accreditation of Healthcare Organizations