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Hunter J, Porter M, Cody P, et al. Int Emerg Nurs. 2022;63:101174.
Many aspects of crew resource management in aviation, such as the sterile cockpit, are used in healthcare to increase situational awareness (SA) and decrease human error. The situational awareness of paramedics in one US city was measured before and after receiving a targeted educational program on situational awareness. There was a statistically significant increase in SA following the intervention, although additional research is needed with larger cohorts.
Aljuaid J, Al-Moteri M. J Emerg Nurs. 2022;48:189-201.
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.
Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2022;62:e139-e147.
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.
Schroers G, Ross JG, Moriarty H. Jt Comm J Qual Patient Saf. 2021;47:38-53.
Medication errors are a common source of patient harm. This systematic review synthesizing qualitative evidence concluded that nurses’ perceived causes of medication administration errors are multifactorial, interconnected, and stem from systems issues. Perceived causes included lack of medication knowledge, fatigue, complacency, heavy workloads, and interruptions.
Deacon A, O’Neill T, Delaloye N, et al. Hosp Pediatr. 2020;10:758-766.
This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.
Duke Center for Healthcare Safety and Quality.
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.
Mazer LM, Bereknyei Merrell S, Hasty BN, et al. JAMA Netw Open. 2018;1:e180870.
Disruptive and unprofessional behaviors are still common in health care, despite positive culture change. This review described formal programs to reduce mistreatment of physician learners. An Annual Perspective reviewed efforts to enhance the culture of safety in medical education.
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.
Petrovic MA, Scholl AT. Cureus. 2018;10:e2339.
Disruptive behavior affects patient safety, clinician burnout, and staff retention. This review discusses the scope of the term "disruptive behavior" to illustrate the lack of a consistent definition of such behavior. The authors submit that a single definition is needed to develop effective policy and research programs for responding to and addressing the problem.
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.
A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.
van Pelt M, Weinger MB. Anesth Analg. 2017.
Distractions and interruptions are prevalent in health care delivery. This conference report reviews types of distractions in anesthesiology, their likelihood to introduce significant risks into care processes, and strategies to help manage distractions.
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.
Wright I. AORN J. 2016;104:536-540.
Noise in the operating room can contribute to miscommunication, stress, and fatigue. This commentary describes a project that established a designated quiet space in an outpatient surgical setting to decrease opportunities for distraction in perioperative care and provided education regarding the importance of noise reduction.
Hayes C, Jackson D, Davidson PM, et al. J Clin Nurs. 2015;24:3063-76.
This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.
Mentis HM, Chellali A, Manser K, et al. Surg Endosc. 2016;30:1713-24.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.

Albarran J, Scholes J, eds. Nurs Crit Care. 2015;20(4):167-220.

Nurses have a key role in patient safety and advocacy in critical care settings. Articles in this special issue explore the impact of interruptions on nursing care, ward rounds as an opportunity for checklist use, and the importance of integrating safety concepts into nursing education.
Monteiro SD, Sherbino JD, Ilgen JS, et al. Acad Med. 2015;90:511-517.
This study used written medical cases to examine whether simulated time pressure or interruptions affect diagnostic accuracy among resident and attending emergency medicine physicians. While the experienced physicians answered the questions more quickly and accurately compared to resident physicians, diagnostic accuracy was not compromised by time pressure or interruptions for either group in this study.
Thomas I, Nicol L, Regan L, et al. BMJ Qual Saf. 2015;24:154-61.
Interruptions are common in the clinical environment and pose a significant safety hazard for health care providers performing complex tasks. This educational intervention used a simulation of ward rounds for final year medical students. Investigators examined rates of errors following interruptions or distractions. One group received targeted feedback on managing distractions while the control students received no feedback. Although simulation reduced the number of errors following interruptions and distractions, feedback conferred an additional decrease in errors as well. This work demonstrates that medical students are not adequately trained to manage common distractions and interruptions. Simulation with targeted feedback is an effective strategy for medical students to safely manage distractions and interruptions. A past AHRQ WebM&M commentary reflects on the relationship between interruptions and errors.