Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.
This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
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.
Matern LH, Farnan JM, Hirsch KW, et al. Simul Healthc. 2018;13:233-238.
Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.
Carlile N, Rhatigan JJ, Bates DW. BMJ Qual Saf. 2017;26:24-29.
Despite the ubiquity of smartphones, the vast majority of physicians still rely on one-way pagers for communication. This study analyzed the frequency and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an average of 22 pages per day, of which 76% were deemed clinically relevant by independent reviewers and 82% required a response. This represented a nearly 50% increase in the volume of pages compared to 1988. Doctors on regionalized services (where patients were admitted to a common unit) received significantly fewer pages than those caring for patients on nonregionalized services, implying that regionalized services may aid face-to-face communication. As interruptions have been shown to negatively affect patient safety, the authors advocate for developing secure two-way methods of communication (such as secure text messaging) for nurses and physicians in order to improve the efficiency of communication around clinical issues.
Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.
This study surveyed nurses in neonatal intensive care units about missed nursing care. As in other care settings, missed nursing care is significant, and reasons include interruptions, urgent patient situations, and increases in patient volume. This finding underscores the need to enhance nursing workflow to prevent errors of omission.
Nguyen C, McElroy LM, Abecassis MM, et al. Int J Med Inform. 2015;84:101-10.
Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.
Peterson SM, Gurses AP, Regan L. J Emerg Med. 2014;47:573-9.
According to this study, information regarding the plan of care was generally accurately transmitted during resident handoffs in the emergency department. However, medications were often omitted and residents were frequently interrupted.
Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
Li SYW, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.
Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.
Kalisch BJ, Aebersold M. Jt Comm J Qual Patient Saf. 2010;36:126-132.
This study observed nurses for 4-hour periods and found that interruptions and multitasking were common. Although nurses managed these discontinuities well, the potential for errors is present and should be a target for prevention strategies.
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.
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