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Journal Article > Review
Rivera-Rodriguez AJ, Karsh BT. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
Tools/Toolkit > Government Resource
Washington, DC: US Department of Defense, Patient Safety Program.
Journal Article > Commentary
The role of theory in research to develop and evaluate the implementation of patient safety practices.
Foy R, Ovretveit J, Shekelle PG, et al. BMJ Qual Saf. 2011;20:453-459.
The first decade of the patient safety movement has seen notable successes, but many highly publicized practices have been less impactful than anticipated. This AHRQ-funded expert panel calls for patient safety researchers to explicitly incorporate theories of individual behavior change and organizational improvement into the planning, implementation, and evaluation of patient safety research. Using established theoretical models has the potential to improve the odds of successful implementation of safety practices and increase the generalizability of successful strategies for other institutions. The importance of behavior change models in implementing checklists was discussed in a recent commentary, and Dr. Brent James—one of the nation's leading physician quality improvement experts—discussed his use of change theories in an AHRQ WebM&M interview.