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Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2021;Epub Sep 12.
Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17(6):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).
Small K, Sidebotham M, Gamble J, et al. Midwifery. 2021;102:103074.
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.
Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;47(9):556-562.
Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33(2):mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Gui JL, Nemergut EC, Forkin KT. J Clin Anesth. 2020;68:110110.
Distractions and interruptions are common in health care delivery. This literature review discusses the range of operating room distractions (from common events such as “small talk” to more intense distractions such as unavailable equipment) that can affect anesthesia practice, and their likely impact on patient safety.
Koch A, Burns J, Catchpole K, et al. BMJ Qual Saf. 2020;29(12):1033-1045.
This systematic review evaluated the relationships between intraoperative flow disruptions (eg, interruptions, equipment malfunctions, unexpected patient conditions) and provider, surgical process, and patient outcomes. On average, 20.5% of operating time was attributed to flow disruptions and these disruptions were either negatively or not substantially associated with surgical outcomes. The authors observed substantial heterogeneity of the evidence base and provided recommendations for future research on the effects of flow disruptions in surgery.
Bonafide CP, Miller JM, Localio AR, et al. JAMA Pediatr. 2019;174(2):162-169.
Interruptions are common in busy clinical settings but carry patient safety concerns, particularly if they occur during medication administration. This retrospective cohort study examined one hospital’s timestamped telecommunications data to determine the effect of incoming mobile calls or texts on subsequent medication errors (based on barcode alerts) in a pediatric ICU. Medication administration errors were more common when nurses were interrupted by incoming telephone calls (3.7%) compared to when they were uninterrupted (3.1%), and error risk varied by shift, level of experience, nurse to patient ratio, and level of patient care required. Incoming text messages were not associated with medication administration errors; the authors speculate that this may be attributable to the fact that text message alerts do not require immediate response or that nurses have become accustomed to their frequent occurrence.
Khairat S, Whitt S, Craven CK, et al. J Patient Saf. 2021;17(4):e321-e326.
Despite many technological innovations, safety events occur frequently in critical care settings. This observational study of critical care rounds found that more safety events occurred when technology such as computer alerts, phones, and pagers interrupted physicians. A previous WebM&M commentary discussed an incident involving a technology interruption that led to serious patient harm.
Joseph R; Harry E.
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.
Olmstead J. Nurs Manage. 2019;50:8-10.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
Joseph A, Khoshkenar A, Taaffe KM, et al. BMJ Qual Saf. 2019;28(4):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.
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.
Schneider A, Wehler M, Weigl M. BMJ Qual Saf. 2019;28:296-304.
Distractions and interruptions have been shown to adversely affect patient safety, but some interruptions may have a positive impact and actually improve care. In this observational study focused on interruptions of doctors and nurses in a single emergency department (ED), researchers found a positive association between interruptions initiated by patients and patient perceptions of ED care quality and efficiency.
Dhillon NK, Francis SE, Tatum JM, et al. JAMA Surg. 2018;153:1052-1053.
In this prospective study, researchers found that decreasing the number of computers on wheels during rounds in a single surgical intensive care unit was associated with a significant reduction in simultaneous conversations and improved ability to hear patient presentations. The authors conclude that participants may be more engaged during rounds when information is obtained from presentations rather than having the electronic medical record readily available on a computer.
A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.
Westbrook JI, Raban MZ, Walter SR, et al. BMJ Qual Saf. 2018;27:655-663.
This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.
Craker NC, Myers RA, Eid J, et al. J Nurs Adm. 2017;47:205-211.
Interruptions are a known patient safety hazard. This direct observation study demonstrated that intensive care unit nurses were interrupted about every 20 minutes. Interruptions by physicians were of longer duration and were more likely to result in the nurse moving to another activity. The authors conclude that further study is needed to determine the clinical significance of interruptions in the intensive care unit setting.
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.