homes as occurring frequently and requiring them to repeatedly revise plans, alter directions, and cease activities prior to completion (Bowers et al., 2001). In a random sample survey of nurses licensed to work in Illinois and North Carolina, conducted as part of a longitudinal study of nurses’ worklife and health funded by the National Institute for Occupational Safety and Health (NIOSH) of the U.S. Centers for Disease Control and Prevention (CDC), 75 percent of the 674 RN respondents who were currently employed as a full-time hospital or nursing home general-duty/staff nurse agreed or agreed strongly that “my job requires long periods of intense concentration”; 82 percent similarly agreed that “I work very fast”; and 79.6 percent agreed that “tasks are often interrupted without being completed.”13

Studies of crew resource management in aviation provide insight into how to limit the effects of interruptions and distractions in that setting (Dismukes et al., 1998). Similar strategies have been employed for evaluating errors in operating rooms (Cooper et al., 1984). However, strategies for reducing interruptions and distractions in nursing settings have not been well developed. A quasi-experimental study of two interventions in a medical–surgical unit (an active avoidance protocol for staff and wearing of a color-coded vest with a warning to avoid interrupting a nurse who is administering medications) found that interruptions and distractions could be significantly reduced (Pape, 2003). Other strategies include closing the patient’s door while conducting bedside care and using manual or electronic message boards to convey nonurgent requests.

Instilling redundancy and back-up systems High-reliability organizations and other safety-conscious organizations design redundancy into their production processes to ensure that there are several ways to identify problems before they become catastrophic. For example, the control tower of a navy aircraft carrier, which is responsible for all activity on the flight deck and hangar, uses more than 20 devices to ensure communication with critical parts of the ship. The landing signal officer on the flight deck is connected directly to the air commander in five different ways: a regular telephone, two sound-powered hot lines, two radios, and a public address system. These multiple communication channels are supplemented by the tower’s capability to call the deck “foul” or not ready to receive an airplane, which serves as one final way to communicate with the landing signal officer. Similarly, airlines have two qualified pilots on each commercial flight, and air traffic controllers work in pairs. Members of such organiza-


Unpublished data from Alison Trinkoff, Ph.D., University of Maryland at Baltimore, NIOSH grant R01OH3702 (personal communication, April 9, 2003).

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