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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.
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.
In response to multiple incidents of registration-associated patient misidentification (eg, assigning a new patient an existing patient's medical record number), an interdisciplinary team used plan-do-study-act methodology to investigate the root cause of such errors and formulate solutions. Several system problems were identified, ranging from inadequate training of registrars to the lack of a true master list of patients' medical record numbers. The authors describe the iterative process used to identify and address sources of error at several points within the patient registration process.