Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17:e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).
Challenges associated with electronic health record design and implementation contribute to interruptions, workarounds, and information overload. This book explores topics relevant to workflow disruptions that can degrade safe practice. The chapters review strategies such as data analysis techniques and human factors engineering to generate improvements.
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.
Joseph A, Khoshkenar A, Taaffe KM, et al. BMJ Qual Saf. 2019;28:276-283.
This direct observation study found that minor disruptions in usual workflow can combine to lead to an adverse event. More than half of the observed disruptions were related to the physical layout of the operating room, suggesting that physical design of operating rooms may affect surgical safety.
Medford-Davis LN, Singh H, Mahajan P. Pediatr Clin North Am. 2018;65:1097-1105.
The busy and complex emergency department environment harbors pressures can that hinder diagnostic safety. This review discusses the characteristics of emergency medicine that contribute to overreliance on heuristics and susceptibility to bias in decision making. The authors highlight the need to better monitor diagnostic error in the emergency department to inform the design of improvement activities. A previous WebM&M commentary discussed diagnostic delay in the emergency department.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.
This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.
Alarm fatigue can affect clinician performance and well-being. This commentary examines the problem of alarm fatigue, factors that contribute to nuisance alarms, and successful reduction strategies such as bundled approaches that include computer analytic techniques and human factors engineering. A WebM&M commentary discussed harm that can result from alarm fatigue.
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.
Allan SH, Doyle PA, Sapirstein A, et al. Jt Comm J Qual Patient Saf. 2017;43:62-70.
Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.
Skaugset M, Farrell S, Carney M, et al. Ann Emerg Med. 2016;68:189-95.
Interruptions and task-switching are common contributors to complexity in emergency care. Exploring behaviors associated with multitasking in various disciplines, including human factors engineering, cognition science, and business, this review outlines a framework for enhancing understanding of multitasking, such as whether it can be performed successfully and types of actions that can be combined safely.
Bravo K, Cochran G, Barrett R. J Nurs Care Qual. 2016;31:335-41.
Medication administration errors are common and are often associated with interruptions. This study reviews data from a recent study on medication safety in critical access hospitals and recommends organizational strategies to improve the safety of medication administration.
Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.
Zheng K, Ciemins EL, Lanham HJ, et al. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.
Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.
Nurses have a key role in patient safety and advocacy in critical care settings. Articles in this special issue explore the impact of interruptions on nursing care, ward rounds as an opportunity for checklist use, and the importance of integrating safety concepts into nursing education.
Errors in surgical care are often associated with human factors, interruptions, and staffing issues. This commentary describes a program to augment safety in ambulatory surgery centers, which includes a surgical checklist, change management, and teamwork.
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.
Dandoy CE, Davies SM, Flesch L, et al. Pediatrics. 2014;134:e1686-e1694.
Improving alarm systems to mitigate the risks of alarm fatigue was added as a National Patient Safety Goal in the 2014 update. This study introduced a multifaceted cardiac monitor care process on a pediatric bone marrow transplant unit. The program included standardized steps for ordering and reassessing cardiac monitor parameters. In addition, physicians and nurses used a log to document the need for ongoing cardiac monitoring and created reliable systems for discontinuation of monitoring when it was no longer needed. Patients and families were actively engaged in these activities, helping sustain the program. As compliance with the process improved from 38% to 95%, the number of alarms per patient-day plummeted from 180 to 40. The hope is that reducing unnecessary alerts will address clinician desensitization to clinically important alarms.
Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014;23:884-92.
This study used high-fidelity simulation to evaluate the impact of several interventions on preventing medication administration errors by chemotherapy nurses. Interventions with a basis in human factors engineering principles appeared to be highly effective at reducing errors related to interruptions.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
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