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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.
Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326:1207-1208.
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.
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.
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.
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.
Gabler E. New York Times. 2020;Jan 31.
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.
Zheng K; Westbrook J; Kannampallil TG; Patel VL.
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.
Quick Safety. October 1, 2018;(45):1-2.
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.
Harvey J, Avery AJ, Ashcroft D, et al. Res Social Adm Pharm. 2015;11:216-27.
This qualitative study characterized safety hazards in medication dispensing in community pharmacies. The authors conclude that the major sources of risk pertained to interruptions and distractions, which were often exacerbated by production pressures.
Sevdalis N, Undre S, McDermott J, et al. World J Surg. 2014;38:751-8.
Researchers performed observations of procedures in operating rooms to examine the effect of distractions on safety. This study revealed that distractions in this setting are prevalent and were frequently linked to omission of intraoperative safety checks. These results are consistent with prior studies of interruptions and patient safety.
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.
Liu W, Manias E, Gerdtz M. Health Place. 2014;26:188-198.
At an Australian hospital, frequent interruptions, limited space, and equipment problems were among many aspects of the physical environment that hinder the medication administration process. An AHRQ WebM&M perspective discusses how restructuring the physical work environment can be a key component of safety efforts.
Raban MZ, Westbrook JI. BMJ Qual Saf. 2014;23:414-21.
Interruptions are inevitable in the busy clinical environment and may contribute to preventable harm, particularly if they occur during medication administration. This systematic review attempted to synthesize research regarding the effectiveness of interventions that have been tested to limit interruptions during medication administration. These efforts included sterile cockpit approaches derived from the aviation industry. Although some interventions did reduce interruption rates, medication error rates were largely unaffected and the literature has significant methodological flaws. The authors caution that hospitals should not attempt to simply limit interruptions, because there is no clear evidence that doing so will prevent medication errors and some interruptions are necessary for patient care.
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.
Colligan L, Guerlain S, Steck SE, et al. BMJ Qual Saf. 2012;21:939-47.
Interruptions during medication administration are a major contributor to medication errors in hospitals. However, interventions to minimize interruptions could have unintended consequences, since certain interruptions are necessary for clinical care. To minimize interruptions while preserving a patient-centered environment, this study used a human factors engineering approach to analyze the medication preparation process and redesign the physical location where the process took place. This approach resulted in significantly fewer interruptions and improved staff satisfaction with medication administration. This study provides an excellent example of how human factors principles can be used to improve the physical environment within a hospital to enhance patient safety.
Katz-Sidlow RJ, Ludwig A, Miller S, et al. J Hosp Med. 2012;7:595-9.
Smartphones have become nearly ubiquitous among physicians. Their use provides many potential benefits for patient care including quick access to medical references, patient information, and clinical applications. However, this mobile technology also introduces a novel source of distractions, interruptions, and multitasking, which have all been linked to medical errors. This cross-sectional survey at a university medical center revealed that both residents and faculty frequently use smartphones during attending rounds. The majority of physicians in the study agreed that smartphones may create serious distractions during rounds. Nearly 80% of attendings believed that formal policies for smartphone usage during rounds should be established. A case of a non–work-related text message on a smartphone that interrupted an important medication order is described in this AHRQ WebM&M commentary.