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Decreasing medical errors by reducing nurses’ cognitive overload

In Australia, medical errors result in as many as 18,000 unnecessary deaths, while more than 50,000 patients become disabled each year.

Estimates suggest that 86 per cent of these events occur in a hospital setting.1

Medical errors can be caused by a number of preventable factors, such as incorrect diagnoses or choosing the wrong medication.2 Improving communication in hospitals can help lower the incidence of medical errors by reducing nurses’ cognitive overload.

Nurses in hospital settings constantly segment what’s important and urgent. When they receive too much information at once, they can become overloaded and have difficulty segmenting, which can lead to mistakes.

Nurses also constantly split their attention across multiple sources and have to pay attention to too many things at once. This can leave them unable to focus on a critical patient care task.

Inevitably, this leads to mistakes.

The amount of information nurses need to deal with can quickly escalate. A constant stream of information means that nurses must maintain total concentration, make sense of that information, and decide how to act based on that information.

There are three types of cognitive load that can contribute to nurses becoming overwhelmed. These are:

Intrinsic cognitive load

This is the amount of effort required to complete a problem or task.

In ordinary circumstances, completing each task correctly and efficiently is likely to be well within a nurse’s cognitive capabilities. However, this intrinsic load can be affected by stress factors that are known to compromise a person’s working memory.

This can include things like lack of sleep, challenging relationships with colleagues, or previous errors. Large, deep emotions such as shame, guilt or grief can contribute to an increased intrinsic cognitive load.

In a busy hospital environment, nurses can struggle to achieve effective communication.

They are receiving messages and instructions from colleagues and physicians, and they can be hindered by barriers such as multiple standards, conflicting protocols, and disparate communication tools. They often have to adapt their working style to suit the physicians on duty.

Furthermore, nurses are often over-notified regarding even minor changes to their patients’ conditions.

They may receive a notification of their patient’s vital signs every 10 minutes even if the patient is stable, or they may be notified of small changes that don’t require a response or intervention. All of this combines to create a drain on working memory.

Extrinsic cognitive load

This is the level of cognitive effort that the clinical environment demands.

Nurses have very little control over this type of cognitive load because it comes from external stressors such as being bombarded with information, being given conflicting or confusing messages, or being given lots of information at once.

When nurses can’t control the flow of information or how they’re receiving it, this can become an extremely stressful process that compromises their ability to deliver optimum care.

Nurses often have to split their attention between multiple patients, information sources and tasks. Added to that, they are often working at the top of their licence or accreditation, which means the work they do tends to be challenging.3

Multitasking and frequent interruptions are a feature of nurses' daily lives. One study revealed that nurses were most likely to be interrupted and to multitask during the administration of medication, which creates risk for patient safety. 4

At the same time, nurses spend a significant portion of their day on documentation. One study found that nurses spend at least 25 per cent of their time charting, updating and reviewing patients’ electronic health records.5

Often, nurses have to create redundant documentation, writing the same information three or four times in different places, while still juggling the care and information related to their patients.

Germane cognitive load

This is the effort that people have to expend to make sense of new information.

If all the information is provided to a nurse in one message, then they can make sense of that information relatively easily. They can then determine the next best correct action to take based on that information.

However, if they’re presented with information out of context and need to check other systems or past notes and files to understand that information, then their germane cognitive load gets heavier.

Too often, nurses are given pieces of information in isolation. For example, they may be provided with a lab value but, without contextual information, that lab value isn’t useful.

This creates additional work as the nurse seeks the right data on which to base their actions.

When all three of these types of loads are heavy at the same time, it becomes clear that nurses are labouring under significantly adverse conditions.

The demands being placed on them can quickly lead to minor and major errors, and can culminate in burnout, leading highly trained and otherwise-capable nurses to seek new careers.

Even before the pandemic, a Monash University national survey found that 32 per cent of nurses and midwives were actively considering leaving the profession.6

At that point, the federal government was already estimating a workforce shortfall of 85,000 by 2025.7

Nurses who stay in the profession could find themselves even more overworked if this shortfall isn’t addressed, which could lead to even more errors.

Hospitals can overcome these issues by standardising on a single clinical communication and collaboration platform that minimises cognitive overload.

By removing the need for retrieve, retain, and record information, these solutions can reduce the cognitive burden and make it easier for nurses and other healthcare colleagues to communicate effectively, thus reducing the risk of errors.

(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117772/
(2) An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. Med J Aust. 1999 May 3; 170(9):411-5.
(3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371290/
(4) How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals. Westbrook JI, Duffield C, Li L, Creswick NJ BMC Health Serv Res. 2011 Nov 24; 11():319.
(5) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371290/
(6) https://leadershipdimensions.com.au/burnt-overworked-australias-nurses-midwives-consider-leaving-profession/#:~:text=A%20Monash%20University%20national%20survey,actively%20considering%20leaving%20the%20profession.
(7) https://www.health.gov.au/internet/main/publishing.nsf/Content/34AA7E6FDB8C16AACA257D9500112F25/%24File/AFHW%20-%20Nurses%20overview%20report.pdf

Alan Stocker is the acting general manager of Connected Health AU.

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One comment

  1. I always wonder where people get the massive numbers of people who are claimed to die of medication errors in hospital. You say that approximately 15,500 die in Australian hospitals from medication error each year (86% of 18,000).

    But the ABS says a total of just over 86,000 died in hospital in 2019. (https://www.abs.gov.au/statistics/research/classifying-place-death-australian-mortality-statistics )

    So almost 1 in 5 deaths in hospital are caused by medication errors by your number. Where does this number come from, since the papers I have read are estimates, based on guesses. I have not seen any research which can accurately say how many people were killed by medication error. And we should be doing just this research.

    I agree that a lot of errors are made in hospitals, by overloaded staff, and by systems, imposed by senior management, which seem to be designed to cause errors, in the name of “efficiency”, or to use nurses and doctors as data entry clerks.

    As a clinician of 20 years plus experience, I have seen many medication errors, but none that seriously harmed a patient.

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