Ali A, Miller MR, Cameron S, et al. Pediatr Emerg Care. 2022;38:207-212.
Interhospital transfer of critical care patients presents patient safety risks. This retrospective study compared adverse event rates between pediatric patient transport both with, and without, parent or family presence. Adverse event rates were not significantly impacted by parental presence.
Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.
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).
Udeh C, Canfield C, Briskin I, et al. J Am Med Inform Assoc. 2021;28:1791-1795.
Computerized provider order entry (CPOE) systems have the potential to reduce error, but their poor CPOE design, implementation and use can contribute to patient safety risks. In this study, researchers found that restricting the number of concurrently open electronic health records did not significantly reduce wrong patient selection errors in their hospital’s CPOE system.
Mahadevan K, Cowan E, Kalsi N, et al. Open Heart. 2020;7.
Distractions and interruptions are common during delivery of health care. In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found that fewer than half of all procedures were completed without interruption or distraction. The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and improve patient safety.
Schroers G, Ross JG, Moriarty H. Jt Comm J Qual Patient Saf. 2021;47:38-53.
Medication errors are a common source of patient harm. This systematic review synthesizing qualitative evidence concluded that nurses’ perceived causes of medication administration errors are multifactorial, interconnected, and stem from systems issues. Perceived causes included lack of medication knowledge, fatigue, complacency, heavy workloads, and interruptions.
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.
Despite many technological innovations, safety events occur frequently in critical care settings. This observational study of critical care rounds found that more safety events occurred when technology such as computer alerts, phones, and pagers interrupted physicians. A previous WebM&M commentary discussed an incident involving a technology interruption that led to serious patient harm.
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.
Kellogg KM, Puthumana JS, Fong A, et al. J Patient Saf. 2021;17:e1394-e1400.
Using incident reporting data from a multihospital reporting system over a 3-year period, researchers sought to identify safety events related to interruptions. About 43% of interruption events were reported by nurses, compared to 15% by pharmacists and 7% by physicians. Interruptions most commonly involved a medication-related task.
The health care environment is rife with distractions during cognitive, clinical, and communication processes that increase the potential for error. This commentary focuses on how mobile communication technologies contribute to distractions in health care workers. The author suggests raising awareness of the risks associated with personal communication technology use to reduce problem behaviors and encourage heightened focus on patients. A past WebM&M commentary discussed a task interruption due to texting.
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.
Interruptions are a known patient safety hazard. This direct observation study demonstrated that intensive care unit nurses were interrupted about every 20 minutes. Interruptions by physicians were of longer duration and were more likely to result in the nurse moving to another activity. The authors conclude that further study is needed to determine the clinical significance of interruptions in the intensive care unit setting.
Westbrook JI, Li L, Hooper TD, et al. BMJ Qual Saf. 2017;26:734-742.
This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.
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.
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.
Personal electronic devices such as smartphones are now ubiquitous, and many clinicians use them for both work and personal purposes. Although considered a necessity, these devices can serve as a distraction, which could compromise patient safety. This review found that many certified registered nurse anesthetists and anesthesiologists acknowledge using personal electronic devices in the operating room despite knowledge of the potential risks. Currently, no formal guidelines exist regarding what constitutes inappropriate use of such devices in the operating room. The authors call for further research in order to develop policies to balance the risks and benefits of personal electronic devices. A WebM&M commentary discusses a case where an interruption due to receiving a text message on a smartphone led to a serious medication error.
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