The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
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.
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).
Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;61:761-771.
Patient safety concerns in community pharmacies have been documented in the media. This study sought to examine the association of working conditions and patient safety. Results indicate that while all participants reported negative company climate and workflow, those in chain pharmacies reported significantly more fear of speaking up about patient safety issues than those in independent, big box, or grocery pharmacies.
Small K, Sidebotham M, Gamble J, et al. Midwifery. 2021;102:103074.
Health information technologies intended to reduce patient harm may have unintended consequences (UC). Midwives describe the unintended consequences of central fetal monitoring technology. These consequences included potential loss of patient trust in the midwife, changes in clinical practice, and increased documentation during labor. The authors recommend reevaluation of use of central fetal monitoring due to potential UC without demonstrating improvements in maternal safety.
Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;47:556-562.
Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.
Arvidsson L, Lindberg M, Skytt B, et al. J Clin Nurs. Epub 2021 Jul 6.
Healthcare associated infections (HAI) affect thousands of hospitalized patients each year. This study evaluated working conditions that impact risk behaviors, such as missed hand hygiene, that may contribute to HAI. Main findings indicate that interruptions and working with colleagues were associated with increased risk behaviors.
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.
Deacon A, O’Neill T, Delaloye N, et al. Hosp Pediatr. 2020;10:758-766.
This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.
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.
Browne J, Braden CJ. Am J Crit Care. 2020;29:182-191.
This study explored the relationship between nursing workload and turbulence, or unexpected work complexities and activities. Using responses from a survey of members of the American Association of Critical-Care Nurses, the authors identified several types of turbulence, such as changes in acuity, interruptions, distractions, lack of training, and administrative demands. They found that turbulence was strongly correlated with patient safety risk whereas workload had the weakest association. Acknowledging the difference between nursing workload and turbulence can enhance our ability to target resources in nursing care and improve patient outcomes.
Sinnott C, Georgiadis A, Park J, et al. Ann Fam Med. 2020;18:159-168.
This review synthesized research exploring how operational failures (e.g., distractions, situational constraints) in primary care affect the work of primary care physicians. The literature suggests that operational failures are common, and the gap between what physicians perceive that they should be doing and what they were doing (“work-as-imagined” vs, “work-as-done”) is largely attributed to operational failures over which the primary care physicians had limited control. The authors suggest that future research focus on which operational failures have the highest impact in primary care settings in order to prioritize areas for targeted improvement.
Pharmacists are instrumental to safe medication use in the ambulatory setting. This news story discusses factors in retail pharmacy environment that degrade pharmacists’ ability to safely practice, which include production pressure, required multitasking, and distraction. Strategies highlighted to mitigate the problem that have been inconsistently applied include scheduled breaks and staff supervision limits.
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.
Bonafide CP, Miller JM, Localio AR, et al. JAMA Pediatr. 2019;174:162-169.
Interruptions are common in busy clinical settings but carry patient safety concerns, particularly if they occur during medication administration. This retrospective cohort study examined one hospital’s timestamped telecommunications data to determine the effect of incoming mobile calls or texts on subsequent medication errors (based on barcode alerts) in a pediatric ICU. Medication administration errors were more common when nurses were interrupted by incoming telephone calls (3.7%) compared to when they were uninterrupted (3.1%), and error risk varied by shift, level of experience, nurse to patient ratio, and level of patient care required. Incoming text messages were not associated with medication administration errors; the authors speculate that this may be attributable to the fact that text message alerts do not require immediate response or that nurses have become accustomed to their frequent occurrence.
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.
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.
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.
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.
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