The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Dzisko M, Lewandowska A, Wudarska B. Sensors (Basel). 2022;22:3536.
Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.
Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20:153.
Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.
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).
Mahadevan K, Cowan E, Kalsi N, et al. Open Heart. 2020;7.
Distractions and interruptions are common during delivery of health care. In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found that fewer than half of all procedures were completed without interruption or distraction. The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and improve patient safety.
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.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.
Medford-Davis LN, Singh H, Mahajan P. Pediatr Clin North Am. 2018;65:1097-1105.
The busy and complex emergency department environment harbors pressures can that hinder diagnostic safety. This review discusses the characteristics of emergency medicine that contribute to overreliance on heuristics and susceptibility to bias in decision making. The authors highlight the need to better monitor diagnostic error in the emergency department to inform the design of improvement activities. A previous WebM&M commentary discussed diagnostic delay in the emergency department.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.
Alarm fatigue can affect clinician performance and well-being. This commentary examines the problem of alarm fatigue, factors that contribute to nuisance alarms, and successful reduction strategies such as bundled approaches that include computer analytic techniques and human factors engineering. A WebM&M commentary discussed harm that can result from alarm fatigue.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Westbrook JI, Li L, Hooper TD, et al. BMJ Qual Saf. 2017;26:734-742.
This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.
Allan SH, Doyle PA, Sapirstein A, et al. Jt Comm J Qual Patient Saf. 2017;43:62-70.
Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.
Skaugset M, Farrell S, Carney M, et al. Ann Emerg Med. 2016;68:189-95.
Interruptions and task-switching are common contributors to complexity in emergency care. Exploring behaviors associated with multitasking in various disciplines, including human factors engineering, cognition science, and business, this review outlines a framework for enhancing understanding of multitasking, such as whether it can be performed successfully and types of actions that can be combined safely.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.
Bravo K, Cochran G, Barrett R. J Nurs Care Qual. 2016;31:335-41.
Medication administration errors are common and are often associated with interruptions. This study reviews data from a recent study on medication safety in critical access hospitals and recommends organizational strategies to improve the safety of medication administration.
Grundgeiger T, Dekker S, Sanderson P, et al. BMJ Qual Saf. 2016;25:392-5.
Interruptions are a common occurrence in health care. This commentary suggests that research about interruptions clearly determine definitions, data collection methods, and processes that are affected to enhance understanding regarding the impact of disruptions on patient safety.
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.
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.
Dandoy CE, Davies SM, Flesch L, et al. Pediatrics. 2014;134:e1686-e1694.
Improving alarm systems to mitigate the risks of alarm fatigue was added as a National Patient Safety Goal in the 2014 update. This study introduced a multifaceted cardiac monitor care process on a pediatric bone marrow transplant unit. The program included standardized steps for ordering and reassessing cardiac monitor parameters. In addition, physicians and nurses used a log to document the need for ongoing cardiac monitoring and created reliable systems for discontinuation of monitoring when it was no longer needed. Patients and families were actively engaged in these activities, helping sustain the program. As compliance with the process improved from 38% to 95%, the number of alarms per patient-day plummeted from 180 to 40. The hope is that reducing unnecessary alerts will address clinician desensitization to clinically important alarms.
Verweij L, Smeulers M, Maaskant JM, et al. J Nurs Scholarsh. 2014;46:340-8.
This study used direct observation and interviews to evaluate the effectiveness of tabards, do-not-disturb signs worn by registered nurses dispensing medications in inpatient settings, in preventing disruptions. The authors found a decrease in interruptions and medication errors, suggesting that tabards may augment safety despite controversy regarding their use.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.