Each year around the time of Nurses Week, I write a CNO Perspective report in which I examine a topic I believe to be of current importance to nurse leaders. This year’s report is titled Cognitive Overload, Medical Errors, and a 5-Point Communication Strategy to Help Clinicians Stay Focused. This blog features key excerpts from the report.
Between 250,000 and 440,000 people die each year from medical errors in the U.S., where medical errors are the third leading cause of death.i Distraction has been shown to play a role in nearly 75 percent of medical errors, and studies have demonstrated that cognitive overload is a cause in 80 percent of medical device user errors. ii iii
A survey Vocera® conducted at HIMSS19 with HIMSS Analytics, part of Definitive Healthcare, points to the prevalence of cognitive overload.iv A vast majority of clinical and IT leaders have recognized signs including clinicians appearing stressed or overwhelmed. More than half of survey respondents said clinicians ignore or fail to notice actionable alerts, which are alerts related to a patient’s condition or care.
We humans parse and make sense of what is going on around us through the act of segmenting. As a clinician in a hospital environment, you constantly segment what is important and urgent as you perform ongoing triage among shifting priorities. When you receive too many pieces of information at once, you become overloaded, and it becomes difficult to segment and to focus on critical patient care tasks. This is where mistakes can happen.
A hospital that’s standardized on a single clinical communication and collaboration (CC&C) platform for all clinicians is positioned to employ strategies to address cognitive overload. Hospitals need to offload clinicians’ need to retrieve, retain, and record information, and make it easier to communicate. A comprehensive CC&C platform can make all the difference.
With a comprehensive CC&C platform in place, you can take measures to reduce cognitive load, which include:
1. Contextualize information
Clinicians are often put in the position of having to solve complex problems without full context; this is called autonomous problem solving. You might have a small piece of standalone information, such as a lab value, but you’re unable to slot that information into any file system in your head that makes sense to you.
A strategy for countering autonomous problem solving in the clinical setting is to provide patient identifiers with notifications, along with an information chain of relevant context.
Vocera technology helps relieve the burden of segmenting information by attaching patient information to the patient’s record so it’s easy to access. Our technology can also contextualize information around a patient or situation. We can attach vital signs, lab values, nurse-call information, and other data such as sepsis risk indicators to the profile of a patient who is the focus of a notification or request.
2. Deflect distractions to allow focus on critical tasks
As a clinician, it is common for your attention to be split among multiple information sources as you try to process many details at the same time. This can lead to cognitive overload and leave you unable to focus on a critical task.
With Vocera technology you can put your mobile device on Do Not Disturb mode and divert extraneous information into voicemail. You can listen to your messages when your brain has working capacity available to segment the information they contain. When a matter is truly urgent, a caller can break through Do Not Disturb.
You can also set options to forward incoming calls to another number. Calling workflows can be set to forward incoming calls to other people in a group and then automatically escalate to other groups if no one in the first group is available.
3. Provide a single source of information and standard communication protocols
Clinicians struggle to fundamentally communicate with each other. They are hindered by barriers such as multiple standards, conflicting protocols, and disparate communication tools. The difficulty of communicating is a drain on working memory.
More than half the respondents in our survey of clinical and IT leaders at HIMSS19 think that trying to communicate via technology is a source of cognitive burden for clinicians. The likely reason is that in many hospitals, tools used for communication such as pagers, standalone texting platforms, and some mobile apps are not integrated into a consolidated software workflow.
With Vocera technology, a nurse doesn’t have to use short-term memory to sort out what system to use to contact the doctor. Our technology allows a hospital to create a standard protocol and consolidated software workflow for communication where all clinicians and ancillary staff can work with the same software, using the same nomenclature.
4. Offload the need to retrieve, retain, and record information
Redundancy of documentation is a huge problem in medical care. When you must write the same information three or four times in three or four different places while you’re busy and juggling information about four to six different patients, you’re likely to make a mistake.
Respondents to our survey with HIMSS Analytics of clinical and IT leaders at HIMSS19 overwhelmingly identified documenting and charting in the EHR as a source of cognitive overload.
Vocera technology lets you offload the need to retrieve, retain, and record certain types of information so you don’t need to carry it in short-term memory. Our platform provides a single source of aggregated information that is accessible to the entire care team and doesn’t need to be replicated again and again.
5. Weed out extraneous information
Weeding refers to removing extraneous information from the conversation. With weeding, what is removed is just as important as what is allowed through.
Perhaps a nurse doesn’t need to receive a patient’s vital signs every 15-30 minutes if a patient is stable or be notified when a patient’s SpO2 has dropped down to 88% if the patient normally sats at 88%.
When it comes to management of secondary alert and alarm notifications, Vocera technology accomplishes extraordinary weeding by allowing nuisance notifications to be filtered out. Clinicians receive only the information on which they need to act. We work with hospital clinical and IT leaders to identify which alert and alarm notifications need to be managed, and to set intelligent rules to do it.
Nurses cannot control the amount of information coming at them, nor how it is delivered. If you apply the right tools to help structure information, to offload the need to retain and replicate information, and to weed out nuisance interruptions, you will help reduce the cognitive burden for nurses.
Reducing the cognitive burden helps create a more satisfying work environment and fosters well-being and retention. It allows nurses to function in a more aware and present domain so they can provide a better experience and outcomes for patients.
I would value hearing your questions and concerns about cognitive overload in clinicians, and strategies you’ve employed to address it. I welcome you to connect with me on LinkedIn and to follow me on Twitter @RhondaCNO.
Read the report Cognitive Overload, Medical Errors, and a 5-Point Communication Strategy to Help Clinicians Stay Focused.
i Sipherd, Ray. “The third-leading cause of death in US most doctors don't want you to know about.” CNBC.com, 28 Feb 2018, https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html.
iii Tariq, Rayhan A.; Scherbak. Yevgeniya. “Medication Errors.” StatPearls, National Center for Biotechnology Information, 11 January 2019, https://www.ncbi.nlm.nih.gov/books/NBK519065/.
iiii Faiola, Anthony, PhD MFA; Srinivas, Preethi, PhDc MS; Duke, Jon, MD MS. “Supporting Clinical Cognition: A Human-Centered Approach to a Novel ICU Information Visualization Dashboard.” AMIA Annual Symposium Proceedings Archive, National Center for Biotechnology Information, 5 Nov 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765655/.
iiv Definitive Healthcare, HIMSS Analytics, Vocera. “Research Findings: Technology and Clinician Cognitive Overload – Easing the Pain.” 2019, https://www.vocera.com/himms19-report.