A work observation study of nuclearmedicine technologists:interruptions, resilience andimplications for patient safety

George Larcos,1 Mirela Prgomet,2 Andrew Georgiou,2

Johanna Westbrook2

ABSTRACTBackground Errors by nuclear medicinetechnologists during the preparation ofradiopharmaceuticals or at other times can causepatient harm and may reflect the impact ofinterruptions, busy work environments anddeficient systems or processes. We aimed to: (a)characterise the rate and nature of interruptionstechnologists experience and (b) identifystrategies that support safety.Methods We performed 100 hours ofobservation of 11 technologists at a major publichospital and measured the proportions of timespent in eight categories of work tasks, locationof task, interruption rate and type andmultitasking (tasks conducted in parallel). Wecatalogued specific safety-oriented strategiesused by technologists.Results Technologists completed 5227 tasksand experienced 569 interruptions (mean, 4.5times per hour; 95% CI 4.1 to 4.9). The highestinterruption rate occurred when technologistswere in transit between rooms (10.3 per hour(95% CI 8.3 to 12.5)). Interruptions duringradiopharmaceutical preparation occurred amean of 4.4 times per hour (95% CI 3.3 to 5.6).Most (n=426) tasks were interrupted once onlyand all tasks were resumed after interruption.Multitasking occurred 16.6% of the time. Atleast some interruptions were initiated by othertechnologists to convey important informationand/or to render assistance. Technologistsemployed a variety of verbal and non-verbalstrategies in all work areas (notably in the hot-lab) to minimise the impact of interruptions andoptimise the safe conduct of procedures.Although most were due to individual choices,some strategies reflected overt or subliminaldepartmental policy.Conclusions Some interruptions appearbeneficial. Technologists’ self-initiated strategies

to support safe work practices appear to be animportant element in supporting a resilient workenvironment in nuclear medicine.

BACKGROUNDHealthcare personnel operate in dynamicand busy environments in which urgentand non-urgent tasks vie for attention andprioritisation.1 Multitasking and interrup-tions such as overhead pages, telephonecalls and distractions from other staff andpatients are widespread and may contrib-ute to errors.2–4 Further, deficiencies inwork systems and processes can causeunexpected delays and magnify the chal-lenges.5 Therefore, understanding the rateand nature of interruptions that personnelexperience, how everyday clinical work isdelivered and the systems in which per-sonnel operate merit additional study andresearch in these topics could identifyother ways to improve safety.In nuclear medicine, the maladministra-

tion of radiopharmaceuticals is animportant patient safety issue because theunintended exposure to ionising radiationmay be harmful.6 Research indicates thattechnologists are directly involved inabout 70% of maladministrations,6 butthere has been little evaluation regardingtheir work patterns, the interruptionsthat they experience and the environmentin which tasks are undertaken. Typically,technologists prepare radiopharmaceuti-cals in a designated ‘hot-lab’ area featur-ing appropriately shielded workbenches,sinks, refrigeration for lyophilised pro-ducts, radioactivity counters, disposalbins and other material. Procedures aremostly routine in nature and there isusually adequate notice of the type of

466 Larcos G, et al. BMJ Qual Saf 2017;26:466–474. doi:10.1136/bmjqs-2016-005846

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1Department of Nuclear Medicine & Ultrasound, Westmead Hospital & University of Sydney, Sydney, New South Wales, Australia2Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia

Correspondence toDr George Larcos, Department of Nuclear Medicine & Ultrasound, Westmead Hospital & University of Sydney, Sydney, NSW 2145, Australia; george.larcos@health.nsw.gov.au

Received 27 June 2016Revised 15 September 2016Accepted 16 September 2016Published Online First 5 October 2016

To cite: Larcos G, Prgomet M, Georgiou A, et al. BMJ Qual Saf 2017;26:466–474.

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study required at the start of each working day.Consequently, radiopharmaceuticals are often pre-pared in batches for patients having similar proceduresand then dispensed into separate syringes for lateruse. Urgent procedures are occasionally requested,which necessitates the preparation of some radiophar-maceuticals for an individual patient at short notice.Once prepared, the same or other technologistsdeliver radiopharmaceuticals to injection or scanningrooms for administration to patients. Since most pro-cedures are routine and can take several hours to com-plete the various components of the scan, themajority of studies commence in the morning.Usually, technologists work in teams to undertake pro-cedures, with specific tasks allocated to different indi-viduals; in some cases, however, a single technologistis responsible for the conduct of all tasks related to apatient’s procedure. As well, two different cameras areused to study patients as part of the same procedure,necessitating coordination of staff and resources.Images are subsequently analysed, archived and pre-sented to doctors for interpretation. Technologistshave responsibility for scheduling and coordination ofprocedures, liaison with other health professionals,quality assurance and administrative tasks. Thus, tech-nologists are comprehensively involved in the com-plete cycle of nuclear medicine procedures, workingin dynamic ways with one other, as well as other clin-ical staff, in multiple locations within the department.Patient safety in nuclear medicine may be enhanced

by managing interruptions, since it is possible thatthese contribute to maladministrations, especiallyduring vulnerable tasks such as the preparation ofradiopharmaceuticals.7 ‘Quiet zones’ and other inter-ruption management strategies during medicationpreparation and administration have been trialled onsome general medical wards, but the evidence ofbenefit is weak.8 Further, there may be undesirableconsequences because some alerts or interruptionsfrom equipment or other staff may bolster safety incertain circumstances.2 9 Thus, more empirical evi-dence is needed to inform the development of qualityinterventions in nuclear medicine.Incident reporting is widely used to inform quality

improvement, but provides limited insights into howhealthcare personnel create and maintain safety atwork (as occurs the vast majority of the time). Innuclear medicine, for example, Australian IncidentRegistry data identify circumstances directly related tomaladministrations and it is unsurprising that ensuingquality improvement strategies have sought to remedyperceived deficits in procedural compliance or train-ing.6 10 11 Concern about the narrow focus inherentin identifying what has gone wrong (as reflected inincident report data) has stimulated calls for an add-itional approach in patient safety to explore aspects of‘resilience’ in the workplace.12 In contrast to incidentreporting, assessment of resilience in the workplace

proactively samples a much larger source of data andrefines safety by promoting flexibility rather thancompliance with protocols, guides and training.12 13

That is, understanding how nuclear medicine technol-ogists adapt to unpredictable workloads and disrup-tive events and the strategies they invoke to maintainsafety in dynamic environments with inherent defi-ciencies in equipment, systems and processes5 couldlead to a better understanding of what happens whenthings go right.12 13 An approach incorporating resili-ence could lead to novel quality improvement strat-egies in nuclear medicine, but this requires carefulresearch because resilient behaviours are oftenimplicit.14

Accordingly, the primary objectives of this workobservation study of nuclear medicine technologistswere to: (a) characterise their work patterns, includingthe rate and nature of interruptions they experienceand (b) identify strategies that support safety in theworkplace. A secondary objective was to use theseresults to suggest quality improvement strategies innuclear medicine that may complement those derivedfrom incident reporting.6 11

MATERIALS AND METHODSStudy design and sampleWe conducted a direct observational time and motionstudy in the nuclear medicine department of a majorpublic teaching hospital (975 beds) in Sydney, whichperforms about 5600 general nuclear medicine andpositron emission tomography (PET) studies annually.The department has 11 technologists (six full-timeand five part-time), three of whom are designated as‘seniors’ (ie, responsible for specific administrativeand supervisory roles, in addition to the tasks under-taken by the junior staff ). The 11 technologists havebetween 1 and 23 years of experience (mean=6.6years) post-professional development year (inAustralia, technologists typically receive 3 years of uni-versity training and become registered after a furtheryear of ‘on-the-job’ training). All 11 technologistswere invited to participate and received informationabout the purpose of the study and the nature of theproposed observations. A total of 100 hours of obser-vation were conducted between 07:00 and 16:30 onweekdays from October to December 2015. We allo-cated 50% of the observation sessions to periods inwhich radiopharmaceutical preparatory activities weremost intense (typically, early and midmorning times).To evaluate whether there was an association betweenseniority and rate of interruptions, we devoted 50%of observation sessions to the three senior technolo-gists. To satisfy these two parameters, we determinedon a weekly basis which periods to monitor. If therewas more than one eligible technologist for a givenperiod, we used a random draw to determine the indi-vidual to be observed. There was no departmental

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policy on interruptions, although the use of smart-phones was discouraged except during personal times.

Data collectionOne member of our team, with intimate knowledgeof nuclear medicine processes, unobtrusively observeda participating technologist from several metres andcollected information for periods of 30–120 minwhile they carried out their usual work tasks.Observational data were recorded on a handheldtablet, using the Work Observation Method ByActivity Timing (WOMBAT) software program,15

adapted to a nuclear medicine environment. Eightbroad categories of mutually exclusive work tasks(some with subcategories) were developed after exten-sive observation and pilot testing (table 1). Aresearcher who had extensive experience of theWOMBAT observational approach trained the obser-ver. During pilot testing, the observer and researcheriteratively reviewed and adjusted preliminary findingsto ensure that the full range of technologists’ taskswas captured and appropriately categorised. TheWOMBAT program has previously been shown tohave high (>85%) inter-rater reliability.15 Althoughwe did not specifically assess reliability in this context,

we used the same template and principles to assignnuclear medicine-specific tasks into the various cat-egories for this study. Despite its potentially vulner-able nature,6 11 we did not create a separate workcategory for radiopharmaceutical preparation becausethis task is an important element of indirect care.Nevertheless, its inclusion as a subcategory renderedsufficient transparency for us to separately determinethe rate of interruptions associated with these tasks.Recorded tasks were automatically time-stamped on

data entry and the observer recorded whom thesubject was with and the location where the task wasperformed. Interruptions and multitasking wererecorded using buttons in WOMBAT and weredefined as follows: an interruption occurred when atechnologist ceased a current task to respond to anexternal stimulus; multitasking occurred when thetechnologist continued their current task whileresponding to an external stimulus, for example, pre-paring radiopharmaceutical while talking to a col-league. Tasks which were suspended due tointerruption remain visible in WOMBAT to permitrecording if the original task was resumed. Thisfeature allows recording of the length and nature ofeach interruption and multitask.

Table 1 Nuclear medicine technologist task classification

Task category Definition Included activities

Direct care Tasks directly related to patient care Preparing a camera or room for a scanAssisting a patient before or after a procedureScanning a patientInteracting with patient and/or relative

Indirect care Tasks indirectly related to patient care Review of request forms, bookings, preparationrequirements for testsWashing handsCleaning or preparing workbenches, scan equipment and bedsChanging bed linenRadiopharmaceutical preparationQuality controlAnalysing scanDisposal and/or return of radioactive waste, paperwork

Documentation Data entry into computer or paperwork Recording doses administered, quality control results and patientdemographics

Professionalcommunication

Any work-related discussion with another staff member Communication on scheduling, transfers, preparation for procedures,protocol to be used and handover of careIncludes the use of fixed or mobile phones or pages

Social Any social or personal activity or discussion Personal phone calls and discussionsTea, lunch and personal breaksPrivate readingPrivate email or social mediaBathroom breaks

Supervision andeducation

Any activity focused on teaching or education Supervision of other staff members or studentsMandatory health trainingResearchParticipating in departmental education sessions

Administrative Any administrative activity not directly related to director indirect care or documentation

Preparing rostersPurchase of suppliesMaintenance of equipmentEmployment issues

In transit Work-related movement between rooms or tasks Includes movement between scanning rooms, movement outside thedepartment to visit patients on wards

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In addition to the structured WOMBAT data collec-tion, we employed an iterative process to develop alist of strategies that technologists used to upholdsafety.12 13 The observer used his knowledge ofnuclear medicine processes to identify potentially eli-gible strategies across the spectrum of tasks and in alldepartmental areas. For this part of the study, we didnot specifically focus on the level of the seniority ofthe participant. Rather, the observer documented anybehaviour, for example, placing sticky notes on aradiopharmaceutical phial or choosing not to inter-rupt a colleague, which prima facie contributed tomaintaining or creating safe working situations.Strategies could pertain to an individual’s behaviouror reflect the use of a tool or an agreed strategy usedby the entire cohort. Following observation sessions,the observer then conferred with the participatingtechnologist to ask about the observed strategies andonly those behaviours that had a confirmed safetyintent were retained. Subsequent periods of unstruc-tured observation and discussion at other times withthe same or other participants were used to expandthe list.Once the list of strategies with a confirmed safety

intent had been compiled, the project team then dis-cussed and reached agreement about the classificationof these strategies. For this purpose, we used a previ-ous report16 to classify each recorded strategy accord-ing to four categories. The categories, withdescriptions in parentheses, are as follows: ‘respon-siveness’ (reacting effectively when a situationchanges); ‘attentiveness (taking appropriate actionconsidering the situation at hand); ‘anticipation’ (pro-actively making a decision or taking a course of actionthat has an expected consequence in a given situation)and ‘past experience’ (drawing on existing knowledgeto influence the sequence and nature of workactivities).The research was approved by the hospital and uni-

versity research ethics committees and writteninformed consent was obtained from all 11 technolo-gists, all of whom participated in the study.

Data analysisDescriptive analyses were performed for: the totalnumber of tasks; the total time that tasks were ‘active’in each category (ie, only tasks that were beingactively performed, rather than paused by interrup-tions); the proportion of time spent on various tasksat different times during the day and rates of interrup-tions and multitasking. In addition, we used linearregression to assess the relationship between the inter-ruption rate and the number of tasks, hours of obser-vation and number of nuclear medicine and PETprocedures for that day. We also determined whetherany interrupted tasks were not resumed.Data were analysed in Microsoft Excel (2016) with

pivot tables and 95% CIs were calculated using aPoisson distribution. Student’s t-test was used tocompare the rate of interruptions experienced bysenior and junior technologists.

RESULTSTask times, interruptions and multitaskingDuring the 100 hours of observation, 5227 tasks wereobserved. The task-specific distribution of technolo-gists’ time is shown in table 2. Direct care tasks con-sumed the highest proportion of technologists’ time(34.6%), although there was a variation during theday. For example, direct care tasks represented about40% of all tasks at 09:00, increasing slightly in pro-portion at 14:00, from which time their proportiontapered to about 20% by the end of the working day.Indirect care tasks were the next most frequent innumber (28.8%), but these were most predominantbetween 07:30 and 09:00, when technologists werepreparing for the various procedures scheduled forthe day. Supervision, social and administrative tasksalso displayed distinct variations according to the timeof day. The mean time allocated to each of the eightwork categories from 07:00 to 16:30 is shown infigure 1.There were 116.6 task hours during the 100 hours of

observation, demonstrating that technologists multi-tasked 16.6% of their time. The highest rate of

Table 2 Distribution of task times, multitasking and interruption rates

Task categoryNumber of tasks(%)

Task time(hours)

Mean tasktime (s)

% task time spent multitasking(95% CI)

Interruption rate per hour,(95% CI)

Direct care 1102 (21.1) 34.6 112 42.8 (26.3 to 59.3) 4.4 (3.8 to 5.1)

Indirect care 1221 (23.4) 28.8 85 20.0 (5.4 to 34.6) 6.0 (5.2 to 6.9)

Documentation 224 (4.3) 3.8 61 12.6 (0 to 46) 8.4 (6.1 to 11.5)

In transit 814 (15.6) 7.3 32 9.9 (0 to 31.6) 10.3 (8.3 to 12.5)

Professionalcommunication

1478 (28.3) 17.7 43 42.2 (19.2 to 65.2) 3.5 (2.7 to 4.4)

Social 196 (3.7) 12.0 220 7.2 (0 to 21.8) 1.4 (0.9 to 2.2)

Supervision oreducation

162 (3.1) 9.2 204 41.6 (9.8 to 73.5) 4.6 (3.4 to 6.0)

Administrative 30 (0.6) 3.2 384 7.8 (0 to 37.2) 4.7 (2.9 to 7.5)

Task times do not add to 100 hours because some tasks were undertaken simultaneously (ie, when multitasking).

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multitasking occurred during direct care or when thetechnologist was supervising or educating another tech-nologist (42.8% and 42.2%, respectively). The multi-tasking rate during indirect care was 20% (95% CI5.4% to 30.6%). A common example was professionalcommunication occurring while preparing a radiophar-maceutical. Multitasking mostly occurred at one pointin time only; however, some individual tasks of longerduration featured several instances of multitasking (upto 13 separate times). Multitasking never involved morethan two tasks simultaneously. The mean duration ofmultitasking was 60 s (range, 1–647 s).Five hundred and sixty-nine tasks (10.9% of the

total) were interrupted, with the highest rate occur-ring when a technologist was in transit (10.3 interrup-tions/hour). The overall interruption rate was 4.5/hour (95% CI 4.1 to 4.9) across all tasks (table 2).

When tasks were interrupted, most (n=426;74.9%) were only interrupted once, but 143 tasks(25.1%) were interrupted on two or more occasions,including one that was interrupted 10 times. Mostinterruptions (n=331; 58.2%) were experienced inscan rooms. The mean time to return to the primarytask was 75 s (range: 3–1289 s). All tasks wereresumed after being interrupted. Interruptions weremost common during mid to late mornings (figure 2).Indirect care tasks were interrupted 6 times/hour(95% CI 5.2 to 6.9), but the subcategory of radio-pharmaceutical preparatory tasks had a mean inter-ruption rate of 4.4 interruptions/hour (95% CI 3.3 to5.6). Senior and junior nuclear medicine technologistsexperienced 5.5 and 4.3 interruptions/hour, respect-ively (p=0.91). The interruption rate per hour wasnot related to the number of procedures, observedtasks or hours of observation for that day (r2=0.11,p=0.67, degrees of freedom=3).

Strategies used by technologists to support safe workThe majority of safe work behaviours were noted inthe hot-lab area, with some consistent examples includ-ing: (a) the use of bar-coding technology to label allsyringes with the correct patient name, radiopharma-ceutical type and radioactivity, (b) manual colourcoding of the daily patient schedule according to theradiopharmaceutical type, (c) quality assurance sum-maries that were prominently displayed as visual aidsin the hot-lab and (d) the early arrival of hot-lab stafffor duty. Behaviours involving communication and/orhandover between staff were most common andincluded both verbal and non-verbal modes. The lattercomprised sticky notes, syringe labels and whiteboardsand again mainly featured in the hot-lab area. Somevisual aids, such as the manual colour coding of patient

Figure 1 Time allocated to different tasks by nuclear medicine technologists from 07:00 to 16:00.

Figure 2 Number of interruptions over a working day.

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lists for batch radiopharmaceutical preparation, actedas an aide-memoire for individuals, rather than a com-munication mechanism between technologists. Further,some strategies reflected decisions made by individualtechnologists at a particular time (eg, not interruptinga colleague or deferring taking a break), althoughothers (such as the implementation of bar-coding forsyringes, the use of a whiteboard and rostering a singletechnologist to therapeutic nuclear medicine) reflecteda deliberate decision by the cohort and its managers touphold safe work practices. We noted that some inter-ruptions among technologists were designed to facili-tate technical information about patients or proceduresor to render assistance in the completion of certaintasks. Among resilient behaviours, responsiveness,attentiveness, anticipation and past experience wereidentified in approximately equal numbers, althoughsome could be classified using more than one charac-teristic (table 3).

DISCUSSIONOur study demonstrated that nuclear technologistsexperienced an interruption on average every 13.3 minthat divert their attention for around 75 s beforereturning to their primary task. Technologists experi-enced an interruption every 13.6 min while preparingradiopharmaceuticals, which is the most safety criticalelement of their work. Some interruptions wereinitiated by other technologists in order to conveyimportant information to one another, facilitate theoptimum conduct of procedures and render assistancein the completion of tasks. Technologists employedvarious strategies, which were mostly self-initiated, tosafeguard tasks that are perceived as vulnerable.The average interruption rate in nuclear medicine is

similar to that reported for doctors working ingeneral community hospital settings3 and slightly lessthan reported for Australian doctors in intensive careunits and emergency departments.17 18 In a previousreview, interruption management strategies, includingthe wearing of manual vests, the use of prominentlydisplayed signs or lanyards discouraging interruptions,checklists and diversion techniques, showed that theevidence for benefit was limited.8 Interruption man-agement strategies may have implications in nuclearmedicine because errors during radiopharmaceuticalpreparation and administration contribute to themajority of maladministrations.6 11 Our data showthat technologists preparing radiopharmaceuticalswere interrupted on average 4.4 times/hour; this isslightly less than the overall average for the depart-ment and much less than in other areas, such as inscanning rooms or while technologists are in transit.Thus, the formal institution of quiet zones in thehot-lab area, even for busier times of the day, mayprovide limited benefit. Further, this type of interrup-tion management strategy could be counterproductivebecause we witnessed examples of other technologists

occasionally interrupting the observed individual toconvey key technical details about specific patients orprocedures or to render assistance for tasks.Multitasking was evident with all task categories,

with the highest rates noted during direct care, profes-sional communication and while supervising othercolleagues. The discrepancy in multitasking ratesbetween task categories probably reflects differencesin the nature of the primary task, its perceived vulner-ability to failure if paused, interruption rate, proxim-ity of other health personnel and patients and theconfiguration of the room in which the task is beingconducted. While multitasking is thought to impose acognitive load and may be deleterious to the primarytask,2 19 the nature and timing of the interaction, thetype of primary task being conducted and character-istics of the persons involved are important contextualfactors.20 As an example, multitasking in the hot-labcommonly involved the participating technologistactively mixing compounds or measuring radioactivitywhile conferring with a colleague about a specificpatient or procedure. This type of multitask permitsthe transfer of important information, without thetechnologist having to pause at critical times duringradiopharmaceutical preparation. Therefore, multi-tasking may foster efficiency in certain circumstances.This is consistent with a previous report21 and sug-gests that restrictions on multitasking, even duringpotentially vulnerable tasks such as radiopharmaceuti-cal preparation may have unwanted consequences.Our results showed that technologists often

employed various strategies to buttress the safeconduct of procedures in specific circumstances andacross all work areas. Some strategies (such as arrivingearly to commence radiopharmaceutical preparatorytasks before peak interruptions were likely to occur oravoiding interrupting colleagues at inopportune times)were explicitly focused on avoiding interruptions,whereas others (such as prominently displayed sum-maries of quality assurance procedures in the hot-lab,appointment of specific technologists to undertaketherapeutic procedures from start to finish and the useof sticky notes on request forms and prepared radio-pharmaceutical syringes to help with informationtransfer) were not. Although many strategies reflectedindividual choices in relation to a particular task, thesetended to be observed in most or all of the technologistcohorts, despite the lack of a formal policy. We suggestthat this indicates the existence of an informal commu-nication network in which potential ‘process failures’are recognised and solutions implemented by the tech-nologists themselves. This type of approach is consist-ent with ‘second-order’ problem solving as reported byTucker and Edmondson.22 However, one importantdifference from their problem-solving model is that,with a few exceptions, most strategies in our studywere implemented without specific managerialinput.

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Table3

Case

exam

ples

ofresilienceinnuclear

medicine

Descriptio

nLocatio

nIndividu

alchoice

orform

alpo

licy

Resilience

characteristic

(s)

Staffarrive

atwork∼10–15

minearlierthan

officially

scheduledto

commence

radiopharmaceuticalpreparation

andavoidinterruptions

Hot-lab

Individualchoice,b

utconsistently

observed

inall

individualsrostered

tothisrole

Anticipatory

Atkeytim

es,technologistspreparingor

administeringradiopharmaceuticalswouldnotrespond

totelephone

calls,overheadpagesor

attemptsby

otherstaffto

initiatecommunication

Hot-lab,scanroom

,injectionroom

Individualchoice,o

bservedon

someoccasions

Responsive,past

experience

Duringradiopharmaceuticalpreparation,

staffkeeptheireyeson

thematerialbeing

prepared

andsometimes

elect

nottorespondto

professionalorsocialcom

municationor

choose

to‘multitask’by

keepingtheirfocus

onthe

materialbeing

prepared

whileresponding

toothers

Hot-lab

Individualchoice,o

bservedon

someoccasions

Responsive,past

experience

Useof

bar-codingtechnology

forindividualradiopharmaceuticals

Hot-lab

Formaldepartm

entalpolicy,usedconsistently

byalltechnologistsrostered

tothisrole

Attentive,past

experience

Useof

stickynoteson

patient

requestformsor

phialsto

convey

keyinformation,

especially

ifatechnologistis

expectingto

beabsent

fora

while

Hot-lab,scanroom

,clerical

area

Individualchoice,b

utconsistently

observed

inall

individualsrostered

tothisrole

Anticipatory

Printout

ofrequestedprocedures

forthe

dayarecolour-coded

fortestsrequiring

different

radiopharmaceuticals

Hot-lab

Individualchoice,b

utconsistently

observed

inall

individualsrostered

tothisrole

Attentive,anticipatory

Printoutsconveyingimportant

elem

entsof

quality

assuranceprocedures

aredisplayedateyelevelinthehot-lab

radiopharmaceuticalworkarea

Hot-lab

Formaldepartm

entalpolicy,usedconsistently

byalltechnologistsrostered

tothisrole

Attentive,past

experience

Technologistsdeferinitiatingconversationwith

acolleague

ifhe/she

appearsbusy

Allw

orkareas

Individualchoice,o

bservedon

someoccasions

Anticipatory,past

experience

Theuseof

whiteboardto

convey

weeklyinformationaboutthe

deliveryof

externalsupplies

Hot-lab

Formaldepartm

entalpolicy,implem

entedby

senior

technologists

Attentive,anticipatory

Someinterruptions,u

suallyintheform

ofprofessionalcom

municationbetweentechnologists,areused

toalert

oneanothertopotentialpitfallsaboutp

roceduresor

patients;forexample,arequestfor

athyroidscan

may

beconvertedto

aparathyroidscan

afterm

edicalreview,thusnecessitatingthepreparationof

adifferent

radiopharmaceutical

Patient

waitingroom

,scan

room

,hot-lab,intransit

Individualchoice,b

utconsistently

observed

inall

individualsinthedirectcareof

apatient

Attentive,responsive,

anticipatory

Multitasking

isfrequently

employed

byalltechnologists,sometimes

toavoidexternalstimulifrominterruptingthe

primarytask

Allw

orkareas

Individualchoice,b

utconsistently

observed

inall

individuals

Responsive

Certainhigh-risk

procedures,particularlytherapeutic

nuclear

medicine,arerostered

toan

individualtechnologist

who

becomes

responsibleforallaspectsof

itsconduct

Hot-lab,scanroom

,patient

waitingroom

Formaldepartm

entalpolicy

adoptedby

all

technologistsrostered

tothisrole

Anticipatory,past

experience

Sometechnologistsdefertheirlunchor

breakinordertostay

inthecontrolroom(adjacenttoscanners)soas

totroubleshoota

nypotentialcom

plications

duringaprocedure

Scan

room

sIndividualchoice,o

bservedinafew

technologists

Responsive,

anticipatory

Someinterrupted

tasksmay

beresumed

byasecond

technologistto

helpcontinue

aprocedureand/or

ensure

quality

ismaintained

Scan

room

s,hot-lab

Individualchoice,o

bservedon

someoccasions

Responsive

Although

moststaffcarry

mobile

telephones,these

areswitchedto

vibrateandarenotlookedat,exceptd

uring

personaltim

eAllw

orkareas

Directive

fromthechieftechnologist

Pastexperience

Ifasenior

technologistdoes

notrespond

toan

overhead

page

ortelephonecall,theclericalstaffredirectthecall

toanotherseniortechnologist

Clericalw

orkarea

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The identification of resilient strategies among tech-nologists has several implications for patient safety innuclear medicine. The technologists were found toimplicitly uphold safety in broad ways and the type ofresilient strategies that are identified may provideimportant clues about underlying organisational defi-ciencies, including inadequate staffing, faulty equip-ment, poor workplace design and miscommunicationamong staff.5 22 Promotion of resilience among tech-nologists should be accompanied by thoughtful ana-lysis and correction of any operational vulnerabilities.For example, changes in quality control requirementsfrom time to time, as well as the exacting nature ofradiochemistry and limited shelf-life of various pro-ducts have been shown to contribute to certain typesof maladministrations.6 Thus, coordination and col-laboration among technologists are critical towardsthe timely delivery and safe preparation of variousradiopharmaceuticals. The use of a whiteboard in thehot-lab is an obvious strategy in our department, butin other facilities could signal the need to modifytechnologist rostering or how tasks are allocated.Radiation protection and patient safety initiatives innuclear medicine in Australia have been developedalmost exclusively from the narrow domain of a statu-tory incident reporting system.6 7 10 11 Our findingssuggest that looking at interventions which supportand enable resilient behaviours could provide add-itional value in improving safety in nuclear medicine.Our research has several potential limitations. First,

errors in the preparation of radiopharmaceuticals rep-resent the main type of maladministrations and canoccur in various settings, including from commercialmanufacturers.6 7 11 Work practices in commercialentities are likely significantly different from those inclinical nuclear medicine facilities. We do not excludethe possibility of benefit from interruption manage-ment in commercial entities. Second, we highlightedcertain strategies among technologists that havecharacteristics of resilience.16 However, refining theapproach would require assessing not just whether aparticular strategy can be identified in any individualtechnologist, but how consistently these are appliedfrom day to day. As well, the interobserver reproduci-bility of the classification system we used is undefinedand is worthy of testing in future studies. Third, ourdata derive from a single institution, but it is one ofthe largest in the country. Nuclear medicine practiceslikely vary, at least subtly, between facilities. The rateof interruptions experienced by nuclear medicinetechnologists at other facilities may differ. Finally, it ispossible that participating technologists may havesubtly altered or improved their work habits becausethey knew that they were being observed. We tried tolimit this effect by spending many hours in pilottesting, thus allowing technologists to become familiarwith the nature of the study. Further, we conductedthe research over 3 months and recorded

technologists’ behaviour on multiple occasions at dif-ferent times of the day, which minimised the likeli-hood for significant persistent changes in behaviours.In summary, nuclear medicine technologists experi-

ence about 4.5 interruptions/hour, mainly in workareas and on tasks not directly related to radiopharma-ceutical preparation and administration. Further, someinterruptions are beneficial and thus, controllinginterruptions per se may be counterproductive.Technologists employ various strategies that upholdsafety, some of which are not specifically related tointerruptions. It is possible to identify resilient beha-viours among technologists and this information mightaid the assessment of individual incidents, as well ascontribute to the identification of new interventionswhich promote patient safety in nuclear medicine.

Acknowledgements We thank Helen Larcos and Scott Walterfor their assistance with the portrayal and analysis of data; andnuclear medicine technologists at our institution for theirwillingness to participate in this study.

Competing interests None declared.

Ethics approval Sydney West Local Health District andMacquarie University.

Provenance and peer review Not commissioned; externallypeer reviewed.

Data sharing statement Original data are stored at theAustralian Institute of Health Innovation (Macquarie University,Sydney, Australia) and can only be accessed by the researchteam members.

Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially, and license their derivative works on differentterms, provided the original work is properly cited and the useis non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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