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August 21, 2016

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Reducing surgical errors: implementing a three-hinge approach to success.

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Landers R. AORN J. 2015;101:657-65.

Errors in surgical care are often associated with human factors, interruptions, and staffing issues. This commentary describes a program to augment safety in ambulatory surgery centers, which includes a surgical checklist, change management, and teamwork.

Interruptions and miscommunications in surgery: an observational study.

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Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-90.

Interruptions were associated with an increased risk of miscommunication between team personnel during surgical procedures. Teams that had limited experience working together seemed to be particularly vulnerable to miscommunications.

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

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West P, Sculli G, Fore A, et al. J Nurs Adm. 2012;42:15-20.

This study reports on the application of a teamwork training intervention to introduce the sterile cockpit concept to bedside nursing activities, with the goal of minimizing interruptions in collection of vital signs and point-of-care testing.

Cognitive Factors in Health Care.

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Rogers WA, ed. J Exp Psychol Appl. 2011;17(3):191-302.

Articles in this special issue explore the impact of cognition on health care activities such as patient identification, interruptions, and team communication.

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

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Hall LMG, Ferguson-Paré M, Peter E, et al. J Nurs Manag. 2010;18:1040-7.

This mixed-methods study characterized the types of interruptions that occur in nurses' daily workflow on medical and surgical units. Most interruptions were by other members of the care team, particularly on medical units.

Triple Handoff

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September 1, 2006

An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.

Strategies used by nurses to recover medical errors in an academic emergency department setting.

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Henneman EA, Blank FSJ, Gawlinski A, et al. Appl Nurs Res. 2006;19:70-7.

The investigators held focus groups to assess how emergency room nurses identify, recover, and correct medical errors. The authors share major themes of methods used in identifying and interrupting errors.

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