Recommendations to reduce cognitive overload

Cognitive overload icon

Emergency department clinicians are challenged to maintain their focus in difficult conditions, increasing the risk that an error will occur

1. Limit interruptions

Develop interruption guidelines: Develop interruption guidelines about appropriate interruptions and educate staff about the harms of unnecessary interruptions.

Assign tasks that cause frequent interruptions to one team member: Assign tasks that cause frequent interruptions (e.g., transfers/lab follow-up) to one team member per shift and realign other tasks so that the assigned team member can focus on only those tasks.

​Set off-limit times/zones for clinicians during critical times: Set certain off-limit times/zones for clinicians during critical times, such as medication prescribing and administration, sign-off and discharge to enable more reliable execution of these critical tasks.

Use tools for communication of non-urgent messages: Tools like an electronic whiteboard or secure text applications allow clinicians to check messages when they have the opportunity rather than breaking their task.

2. Support all members of the care team to practice at the top of his/her license

Implement a scribe program: Medical scribes assist with documentation, reducing the amount of time physicians must spend at the EHR and increasing time for direct patient care. Emergency departments may use scribes to document, perform order entry, admit/discharge, request consults, pull-up prior patient data, and alert providers to new/ important information.

Use the pharmacy team: The pharmacy team may assist with medication selection and safety, care of critically ill patients, antimicrobial stewardship, and calculation of weight-based dosing. Studies show that having a pharmacist on-staff in the ED may reduce medication errors by two-thirds.

Use pharmacy technicians: Use pharmacy technicians to complete medication histories and medication reconciliation. This has been shown to both increase accuracy of medication histories and reduce medication errors by as much as half.

Use paramedics within the ED: Use paramedics within the ED to complete tasks such as triage, starting IVs, and offloading patients from arriving Emergency Medical Services units.

3. Adopt and actively promote the use of cognitive job aids

Identify and implement key clinical pathways: Identify and implement key clinical pathways that are up-to-date and readily accessible to clinicians to help guide triage and treatment of patients.

Use kits or carts: Use kits or carts for select procedures to reduce the need for hunting and fetching of materials and equipment, enabling providers to stay focused on performing the procedure.

Implement checklists: Implement checklists for use during procedures that are high-risk but infrequently performed to reduce the risk of complications.

4. Optimize use of the electronic health records (EHR) system

​Adopt only clinically validated EHR reminders: Adopt only clinically validated EHR reminders to prevent interruptions that are clinically meaningless and poorly targeted.

Consult with clinical end-users of EHR systems: Consult with clinical end-users of EHR systems during development and implementation of EHR systems

​Establish an EHR governance structure: Establish an EHR governance structure to consult with clinical end-users, monitor use of alerts and complete a periodic reassessment to ensure that they are clinically appropriate and relevant.

5. Adopt a team-based approach

Use team huddles: Use huddles at key times to ensure communication of important information.

Promote awareness among team members of each other: Make sure team members are aware of each others' identified roles/ responsibilities and experience level.

6. Support clinical staff in engaging in self-care

Implement a peer support program

Use hospital wellness resources: Use hospital wellness resources to provide specific support to ED clinical teams.

Adopt scheduling strategies that allow ED clinical teams time to meet basic needs: Clinical teams need scheduled time for meals, restroom breaks and lactation.

“The volume of older, sicker, more complicated patients is increasing and we know that the numbers of these patients will be going up significantly over the next decade.”

- Emergency physician, MACEP member