Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor. 

Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.

Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.  

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.

Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.

The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.

I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.

Situational awareness is the degree to which perception of a situation matches reality, and the lack of situational awareness can result in decreased patient outcomes. This study measured nurses’ situational awareness immediately after inspection of a resuscitation cart. Importantly, researchers observed significant issues related to readiness preparedness, such as empty oxygen tanks, drained batteries, and equipment failures.

During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Interhospital transfer of critical care patients presents patient safety risks. This retrospective study compared adverse event rates between pediatric patient transport both with, and without, parent or family presence. Adverse event rates were not significantly impacted by parental presence.

Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.

Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.

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.

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).

Health information technologies intended to reduce patient harm may have unintended consequences (UC). Midwives describe the unintended consequences of central fetal monitoring technology. These consequences included potential loss of patient trust in the midwife, changes in clinical practice, and increased documentation during labor. The authors recommend reevaluation of use of central fetal monitoring due to potential UC without demonstrating improvements in maternal safety.