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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.
Mentis HM, Chellali A, Manser K, et al. Surg Endosc. 2016;30:1713-24.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Scott-Cawiezell J, Pepper GA, Madsen RW, et al. Clin Nurs Res. 2007;16:72-8.
This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.