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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.
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.
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.
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.
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.
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.
Campbell AA, Harlan T, Campbell M, et al. J Nurs Scholarsh. 2021;53:333-342.
Using electronic health records, call light systems, and bar-code medication administration systems, this study examined the impact of six specific workload variables on nurses’ medication administration errors. At least one of the six variables was significantly associated with the occurrence or nonoccurrence of a near miss medication error in the majority of nurses. Because the specific variable(s) differed for each individual nurse, interventions addressing medication administration errors should be tailored to individual nurse risk factors.
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.
Johnson AH, Benham‐Hutchins M. AORN J. 2020;111.
Unprofessional behaviors negatively impact teams and can undermine patient safety. This systematic review examined the influence of bullying on nursing errors across multiple healthcare settings. Fourteen articles were included in the review and four themes were identified: the influence of work environment; individual-level connections between bullying and errors; barriers to teamwork, and; communication impairment. While nurses perceive that bullying influences errors and patient outcomes, the mechanisms are unclear and more research is necessary to determined how bullying impacts nursing practice error.
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.
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.
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.
Duke Center for Healthcare Safety and Quality.
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.
Khairat S, Whitt S, Craven CK, et al. J Patient Saf. 2021;17:e321-e326.
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.
Olmstead J. Nurs Manage. 2019;50:8-10.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
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.
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.
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.