Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44:833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
A 55-year old man was admitted to the hospital for pneumonia requiring intravenous antibiotics. After three intravenous lines infiltrated, the attending physician on call gave a verbal order to have a percutaneous intravenous central venous catheter placed by interventional radiology the next morning. However, the nurse on duty incorrectly entered an order for a tunneled dialysis catheter, and the radiologist then inserted the wrong type of catheter. The commentary explores safety issues with verbal orders and interventional radiology procedures.
Unprofessional behaviors negatively impact teams and can undermine patient safety. This systematic review examined the influence of bullying on nursing errors across multiple healthcare settings. Fourteen articles were included in the review and four themes were identified: the influence of work environment; individual-level connections between bullying and errors; barriers to teamwork, and; communication impairment. While nurses perceive that bullying influences errors and patient outcomes, the mechanisms are unclear and more research is necessary to determined how bullying impacts nursing practice error.
Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.
Rhudy LM, Johnson MR, Krecke CA, et al. Worldviews Evid Based Nurs. 2019;16:362-370.
Nursing handoffs at change of shift are critical for nurses to exchange information about patients; disruptions have been associated with adverse events. After observing 100 nurse-to-nurse handoffs and conducting four focus groups, authors identified multiple sources of disruptions including those by patients and family members, which accounted for half the interruptions outside of the nurse handoff dyad. Nurses identified some interruptions as valuable and relevant to patient care.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.
Schneider A, Wehler M, Weigl M. BMJ Qual Saf. 2019;28:296-304.
Distractions and interruptions have been shown to adversely affect patient safety, but some interruptions may have a positive impact and actually improve care. In this observational study focused on interruptions of doctors and nurses in a single emergency department (ED), researchers found a positive association between interruptions initiated by patients and patient perceptions of ED care quality and efficiency.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Sun AJ, Wang L, Go M, et al. BMJ Qual Saf. 2018;27:156-162.
Interruptions can lead to errors, particularly when providers are sleep deprived. This retrospective cross-sectional study of pages sent to overnight general surgery and internal medicine physicians found that 27.7% were nonurgent. The authors assert that nonurgent paging contributes to alarm fatigue and suggest potential solutions.
Texting as a communication method in the clinical environment is convenient, but it introduces distraction that can result in error. This survey sought to track the prevalence of medical order texting to better understand its impact on care processes.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.
Carlile N, Rhatigan JJ, Bates DW. BMJ Qual Saf. 2017;26:24-29.
Despite the ubiquity of smartphones, the vast majority of physicians still rely on one-way pagers for communication. This study analyzed the frequency and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an average of 22 pages per day, of which 76% were deemed clinically relevant by independent reviewers and 82% required a response. This represented a nearly 50% increase in the volume of pages compared to 1988. Doctors on regionalized services (where patients were admitted to a common unit) received significantly fewer pages than those caring for patients on nonregionalized services, implying that regionalized services may aid face-to-face communication. As interruptions have been shown to negatively affect patient safety, the authors advocate for developing secure two-way methods of communication (such as secure text messaging) for nurses and physicians in order to improve the efficiency of communication around clinical issues.
Nguyen C, McElroy LM, Abecassis MM, et al. Int J Med Inform. 2015;84:101-10.
Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.
Peterson SM, Gurses AP, Regan L. J Emerg Med. 2014;47:573-9.
According to this study, information regarding the plan of care was generally accurately transmitted during resident handoffs in the emergency department. However, medications were often omitted and residents were frequently interrupted.
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. J Patient Saf. 2014;10:29-44.
This direct observation study found that registered nurses, physicians, and nursing aides have frequent interruptions and limited time for shift-change handoffs. This finding suggests that widespread efforts to ensure adequate handoff time and minimize interruptions have not mitigated these problems in hospital settings.
Wu RC, Lo V, Morra D, et al. J Am Med Inform Assoc. 2013;20:766-77.
Safe patient care requires effective communication between health care providers. Hospitals currently use various communication strategies including alphanumeric pagers, smartphones, and Web-based communication tools. The utility and effectiveness of many such systems have not been tested. This ethnographic study of five teaching hospitals discusses the potential benefits and unintended effects of different communication systems. For instance, smartphones made it easier to respond to requests, but seemed to increase interruptions. An AHRQ WebM&M commentary illustrates a serious adverse event resulting from a smartphone interruption.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.