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.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33:mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Freeling M, Rainbow JG, Chamberlain D. Int J Nurs Stud. 2020;109:103659.
This literature analysis assessed the evidence on the impact presenteeism in the nursing workforce and found that presenteeism is associated with risk to nurse well-being and patient safety, but that additional research exploring the relationship between presenteeism, job satisfaction, and quality of care is needed.
Westbrook JI, Raban MZ, Walter SR, et al. BMJ Qual Saf. 2018;27:655-663.
This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.
Johnson M, Sanchez P, Langdon R, et al. J Nurs Manag. 2017;25:498-507.
Interruptions in nursing care are common and can contribute to errors. In keeping with prior research, this observational study of nurses found that interruptions in medication preparation and administration can compromise patient safety.
Gao J, Rae AJ, Dekker SWA. J Patient Saf. 2021;17:e684-e688.
Interruptions can contribute to medication errors, but efforts to reduce interruptions may result in unintended consequences. The authors suggest that designing interventions around high reliability and resilience principles can address risks and increase the likelihood of lasting improvements.
Page N, Baysari MT, Westbrook JI. Int J Med Inform. 2017;105:22-30.
Computerized provider order entry (CPOE) systems improve medication safety by electronically alerting providers to potential prescribing errors and medication safety issues. If a system generates an excessive number of warnings, this can lead to alert fatigue and providers may unintentionally override appropriate alerts. This systematic review examined the impact of different types of medication prescribing alerts in CPOE systems on provider behavior. Researchers included 23 studies and found that the most common alert categories included drug–condition interaction alerts, drug–drug interaction alerts, and corollary order alerts. Although 17 of the studies demonstrated a statistically significant benefit from the intervention alerts, the authors conclude that further research is needed to understand if certain categories of alerts are more effective than others. An Annual Perspective discussed CPOE as it relates to patient safety.
Interruptions are common in care settings and can introduce safety hazards into health care processes. This commentary describes an observational method to explore factors that contribute to interruptions from various perspectives to better understand the reasons for interruptions and design strategies to manage them. A past PSNet perspective discussed an approach to reduce interruptions.
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.
Interruptions are prevalent in health care delivery settings. This review discusses epidemiology, quality improvement, cognitive systems engineering, and applied cognitive psychology as prominent research traditions examining interruptions in health care. The authors suggest that a more integrated approach that combines perspectives from these research traditions could enhance design of interventions to reduce interruptions.
Larcos G, Prgomet M, Georgiou A, et al. BMJ Qual Saf. 2017;26:466-474.
Prior research demonstrates that interruptions in health care can compromise patient safety. In this study, researchers observed interruptions experienced by nuclear medicine technologists in their work environment and found that some interruptions were helpful. In addition, technologists had developed personal strategies to optimize for safety.
Grundgeiger T, Dekker S, Sanderson P, et al. BMJ Qual Saf. 2016;25:392-5.
Interruptions are a common occurrence in health care. This commentary suggests that research about interruptions clearly determine definitions, data collection methods, and processes that are affected to enhance understanding regarding the impact of disruptions on patient safety.
Hayes C, Jackson D, Davidson PM, et al. J Clin Nurs. 2015;24:3063-76.
This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.
Exploring the existing evidence on interruptions in health care, this commentary reveals that most studies focus on the rate of interruptions rather than the relationship between interruptions and errors. The author calls for research to evaluate how use of multitasking behaviors to manage interruptions and to differentiate between appropriate interruptions that prevent errors and those that contribute to preventable harm.
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.
Magrabi F, Li SYW, Day RO, et al. J Am Med Inform Assoc. 2010;17:575-83.
Interruptions during the medication administration process have been linked to an increased risk of error. This simulation study investigated the effect of interruptions on medication prescribing errors, using a controlled experimental design during which physicians were interrupted while prescribing within a computerized provider order entry system. Interruptions did not result in an increase in prescribing errors, but did significantly increase the time needed to complete complex prescribing tasks. The investigators hypothesize that CPOE systems provide visual cues that may help providers resume interrupted tasks without increasing the potential for error.
Westbrook JI, Woods A, Rob MI, et al. Arch Intern Med. 2010;170:683-690.
Interruptions in nursing activities are a known patient safety concern, particularly around medication administration. Most studies describing this relationship are based on self-reported experiences, surveys, or retrospective analysis of voluntary reports. This study directly observed nurses during medication administration and discovered that each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. Interruptions occurred in more than 50% of administrations with error severity increasing with interruption frequency. An alarming finding was that administration without interruptions still generated a procedural failure rate of nearly 70% and a clinical error rate of 25%. The latter findings are discussed further in an invited commentary [see link below] that advocates for greater efforts to improve the medication administration process, including protected times for these activities.
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